Introduction
Death is an inevitable event, and healthcare institutions, in addition to being crucial sites for treatment and care, are also environments in which loss is encountered (Broad et al. Reference Broad, Gott and Kim2013). Bereavement refers to the experience of having lost a loved one (Shear et al. Reference Shear, Ghesquiere and Glickman2013), while professional bereavement is used to describe the grief experienced by professional caregivers following the loss of their patients (Wenzel et al. Reference Wenzel, Shaha and Klimmek2011). To provide quality care, healthcare professionals and patients develop a close relationship, which contributes to the uniqueness of their bereavement experience. The experience of professional bereavement includes a personal dimension of grief, which includes different types of responses, the nature of which may be emotional (continuous grief, loss, helplessness, guilt, anger, powerlessness, emotional exhaustion, depression) (Betriana and Kongsuwan Reference Betriana and Kongsuwan2020; Groves et al. Reference Groves, Adewumi and Gerhardt2022; Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018; Shorter and Stayt Reference Shorter and Stayt2010; Wenzel et al. Reference Wenzel, Shaha and Klimmek2011; Wolfe et al. Reference Wolfe, Hinds and Arnold2022; Yu and Chan Reference Yu and Chan2010; Zhang et al. Reference Zhang, Cao and Su2022), physical (crying, nightmares, exhaustion) (Betriana and Kongsuwan Reference Betriana and Kongsuwan2020; Groves et al. Reference Groves, Adewumi and Gerhardt2022; Wolfe et al. Reference Wolfe, Hinds and Arnold2022; Zhang et al. Reference Zhang, Cao and Su2022), cognitive (numbness, self-doubt, self-stigma), and mental (loneliness, loss of life and hope, death anxiety) (Wenzel et al. Reference Wenzel, Shaha and Klimmek2011); however, it also involves a professional dimension, and can result in a sense of loss of professional goals (Barnes et al. Reference Barnes, Jordan and Broom2020), professional exhaustion, and burnout (Granek et al. Reference Granek, Ariad and Nakash2017).
The bereavement experiences of healthcare professionals have gained attention from researchers in recent years. Papadatou (Reference Papadatou2000) has developed a model of the grieving process as experienced by healthcare professionals. This process which may be understood as a state of continual flux between ruminating on the loss and avoiding grief reactions, and it can be influenced by individual lifestyles and unit work styles. Chen et al. (Reference Chen, Chow and Tang2018) has proposed an integrated model of the bereavement process by ethnographically integrating the bereavement experiences of professional healthcare workers, which incorporating the perceived nature of patient deaths, bereavement responses, and cumulative personal and professional changes. However, there is no framework that focuses on examining how they cope with bereavement. Crunk et al. (Reference Crunk, Burke and Neimeyer2021) developed the 6-dimensional Coping Assessment for Bereavement and Loss Experiences which categorizes strategies into help-seeking, positive outlook, spiritual support, continuing bonds, compassionate outreach, and social support. Unlike family bereavement, professional bereavement involves both an individual and professional dimension, whereby each process is accompanied by a profound change in the individual’s sense of meaning and identity. As a result, professional coping is unique. By experiencing and overcoming their grief, the participants were able to interpret and make sense of patient deaths, which helped them to achieve professional growth (Conte Reference Conte2011).
Death is a traumatic and emotional event that is experienced frequently by care providers, and bereavement is a common stressor for healthcare professionals. According to the stress coping model of Lazarus & Folkman (Folkman et al. Reference Folkman, Lazarus and Gruen1986), coping is defined as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.” Coping with patient deaths is an individual process, and healthcare professionals have their own different subjective perceptions and coping strategies (Zheng et al. Reference Zheng, Lee and Bloomer2018). Different coping strategies may have distinct consequences, which can affect the physical and mental health of healthcare professionals, clinical practices, and even the quality of bereavement care provided (Stabnick et al. Reference Stabnick, Yeboah and Arthur-Komeh2022). Evidence suggests that healthcare professionals are more susceptible to mental illness compared to the general population (Joliat et al. Reference Joliat, Demartines and Uldry2019). In addition, it has been reported that 33.5% of doctors and nurses experience negative emotions and cognitive barriers, as well as a total lack of confidence in their ability to provide bereavement care (Lin and Fan Reference Lin and Fan2020). Therefore, it is critical to examine the coping strategies used by healthcare professionals when they experience the loss of a patient, so as to develop effective interventions and enhance bereavement care. The current study aimed to elucidate the following research question: How do healthcare professionals cope with bereavement, and what coping strategies do they use?
Methods
This paper follows the guidelines of the ENTREQ statement (Tong et al. Reference Tong, Flemming and McInnes2012) which was designed to enhance transparency in reporting the synthesis of qualitative research. A systematic review protocol was developed and registered with the International Prospective Register of Systematic Reviews (PROSPERO) (#CRD42023406061).
Eligibility criteria for selecting studies
Inclusion criteria
Studies were included if they met the inclusion criteria: (1) Participants: Included studies with healthcare professionals as participants, defined as a population who study, advise on or provide preventive, curative, rehabilitative, and promotional health services based on an extensive body of theoretical and factual knowledge in the diagnosis and treatment of disease and other health problems according to the World Health Organization (WHO 2019); (2) Interest of phenomena: Coping strategies or coping experiences of healthcare professionals in response to bereavement; (3) Context: The context included any settings in which professional bereavement was experienced; (4) Study design: Qualitative research methods included but were not limited to phenomenological research, grounded theory, ethnography, or qualitative data from mixed research studies.
Exclusion criteria
(1) Non-English literature, (2) protocols, (3) conference abstracts, (4) duplicate publications, and (5) full text not available.
Search strategies
A combination of subject terms and free words were used for literature searching. The search was conducted in PubMed, Embase, ScienceDirect, CINAHL, PsycINFO, Web of Science, Cochrane Library, Scopus, and Wiley online library in April 2023. Search keywords included “nurs*,” “docto*,” “physician*,” “surgeon*,” “medical personne*,” “health personnel,” “medical staff*,” “health care personne*,” “healthcare professional,” “healthcare provider,” “bereavement,” “grief,” “mourning,” “patient death,” “death of patient,” “patient loss,” “loss of patient,” “experience,” “feelings,” “perception,” “perspective,” “attitude,” “need,” “expectation,” “qualitative research,” “qualitative study,” “phenomenology,” “grounded theory,” “ethnography,” “focus group,” and “case stud*.” The Boolean operator “AND” and “OR” were also used to connect the related concept, and there were no search date limits in this study.
Quality assessment
Two researchers independently assessed the quality of the literature using the Critical Appraisal Skills Programme (2018). A total of 10 items were evaluated, and the suggested answer categories for each evaluation item were: Yes, No, Unclear, and Not Applicable (NA). The Critical Appraisal Skills Programme (CASP) Checklist was used for critical appraisal, and it has been widely applied in qualitative studies. However, it does not provide a scoring system; we therefore used the Reviewer Guidelines for Using the CASP Checklist developed by Butler, which is divided into 3 categories: high, medium, and low. Items with scores less than 6 were eliminated.
Information extraction
Two researchers independently screened the literature by reading the title, abstract, and full text according to the inclusion and exclusion criteria of the literature. A standardized data extraction form was used for data extraction, which contained authors, year of publication, country/region, methodology, data collection method, participants, settings, sample size, data analysis method, and major findings. Group discussions or consultation with third partners were conducted in the event of disagreement during the screening and extraction of the literature.
Data synthesis
The included studies were imported into NVIVO 11 software for inductive coding in thematic narrative synthesis. The 3 stages proposed by Thomas and Harden were followed to guide this synthesis: the coding of text line-by-line, the development of descriptive themes, and the generation of analytical themes. The synthesis was primarily conducted by one researcher, and the findings were discussed and verified by the other researchers.
Results
Study selection
A total of 2092 studies were initially identified, and 1747 studies were retained after removing duplicate records. A total of 1682 studies were excluded after screening the titles and abstracts, and 29 studies were finally included after a thorough review of the full text of the selected 62 articles. One additional study was included by tracking the references of the included literature, and a total of 30 studies were finally included and analyzed. Figure 1 shows the PRISMA flowchart of the whole selection process.
PRISMA flowchart of study selection and exclusion.
Study characteristics
All 30 included studies were published between 1997 and 2022. Twenty-nine were qualitative studies and 1 was an online survey with open-ended questions. Three were doctoral dissertations and 27 were journal publications. Of the 30 studies, 9 were from the United States, 4 from Canada, 3 from Australia, 3 from China, 2 from the United Kingdom, and the remaining 9 were from Canada, Jordan, Thailand, Philippines, Israel, Indonesia, Singapore, Ireland, and South Africa, respectively. The included healthcare professionals included physicians, oncologists, palliative care occupational therapists, speech–language therapists and audiologists, and nurses. The basic characteristics of the included literature are shown in Table 1. The quality scores of included articles ranged from 9 to 10, and the quality of all included studies was high, indicating the reliability of their findings. Table 2 shows the CASP Checklist and scores for the selected papers.
Characteristics of included studies in the review
CASP Checklist and scores for selected papers
Q1 Was there a clear statement of the aims of the research?
Q2 Is a qualitative methodology appropriate?
Q3 Was the research design appropriate to address the aims of the research?
Q4 Was the recruitment strategy appropriate to the aims of the research?
Q5 Was the data collected in a way that addressed the research issue?
Q6 Has the relationship between researcher and participants been adequately considered?
Q7 Have ethical issues been taken into consideration?
Q8 Was the data analysis sufficiently rigorous?
Q9 Is there a clear statement of findings?
Q10 How valuable is the research?
Meta-synthesis of qualitative data
A total of 14 descriptive themes were obtained and analyzed to create 6 analytical categories: emotional coping, cognitive coping, behavioral coping, relational coping, spiritual coping, and occupational coping. Table 3 shows the process of theme development.
CASP Checklist and scores for selected papers
Emotional coping
Two categories of emotional coping were identified: emotional catharsis and emotional detachment. The main method of emotional catharsis was crying (Conte Reference Conte2011; Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021, Reference Shimoinaba, O’Connor and Lee2014; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010). As mentioned by the interviewer, “For me, crying is a necessary process, and I have to get it out.” The participants reported that it was important that they expressed discomfort when they experienced traumatic events, and they could only accept their grief by acknowledging their loss and emotions. Therefore, they chose a form of direct emotional release.
Emotional detachment was identified as another emotional coping strategy used by the participants. This refers to their ability to separate their emotions, which is achieved by maintaining a psychological distance from the patient and their grief (Bacon Reference Bacon2017; Betriana and Kongsuwan Reference Betriana and Kongsuwan2019; Chen et al. Reference Chen, Chow and Xu2023; Chew et al. Reference Chew, Ang and Shorey2021; Conte Reference Conte2011; Gerow et al. Reference Gerow, Conejo and Alonzo2010; Granek et al. Reference Granek, Barrera and Scheinemann2016; Groves et al. Reference Groves, Adewumi and Gerhardt2022; Hinderer Reference Hinderer2012; Mateo et al. Reference Mateo, Carlos and Chua2020; Mirwald Reference Mirwald2019; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021, Reference Shimoinaba, O’Connor and Lee2014; Shorter and Stayt Reference Shorter and Stayt2010; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010; Treggalles and Lowrie Reference Treggalles and Lowrie2018; Wolfe et al. Reference Wolfe, Hinds and Arnold2022; Yu and Chan Reference Yu and Chan2010). Psychological distancing and low engagement were protective mechanisms that helped medical professionals to protect themselves, allowing them to proactively manage triggers of emotional vulnerability, avoid trauma for a short period of time, and manage their emotional health and well-being. Moreover, these strategies were regarded as essential for healthcare professionals, given that they had to provide high-quality care to patients, support grieving families, and remain calm and rational so that they could carry out their professional duties.
Cognitive coping
Cognitive change was identified as an important strategy that helped healthcare professionals to cope with bereavement experiences, and it involved death attribution, reflecting on life and death, and positive reframing.
Death attribution was identified as a form of cognitive coping. To cope with the loss of patients and to avoid self-blame, some participants relied on ideas of fatalism, and believed that the loss of their patient was fated and beyond their control (Yu and Chan Reference Yu and Chan2010). Other participants (Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018) viewed patient deaths as being unrelated to the care provided, or sought rational explanations for patient deaths by framing the experiences within biomedical and sociocultural perspectives (Morrissey and Higgins Reference Morrissey and Higgins2021).
Reflecting on life and death was another important cognitive coping strategy among the participants, as it helped them to come to terms with death and make sense of it. The experience of death enabled the participants to reconceptualize and accept it (Chen et al. Reference Chen, Chow and Xu2023; Gerow et al. Reference Gerow, Conejo and Alonzo2010; Shorter and Stayt Reference Shorter and Stayt2010; Zhang et al. Reference Zhang, Cao and Su2022). They recognized death as an inevitable part of life, realized the sacredness and fragility of life, and even reflected on their work and life (Chew et al. Reference Chew, Ang and Shorey2021; Wolfe et al. Reference Wolfe, Hinds and Arnold2022). In addition, the participants reflected on each death event, the self-coping strategies that they used, and the quality of care provided, while striving to find a sense of meaning and satisfaction in clinical practice (Bacon Reference Bacon2017; Chew et al. Reference Chew, Ang and Shorey2021; Hinderer Reference Hinderer2012; Hogan et al. Reference Hogan, Fothergill-Bourbonnais and Brajtman2016; Nagdee and Andrade Reference Nagdee and Andrade2022; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010; Treggalles and Lowrie Reference Treggalles and Lowrie2018).
The participants also actively and positively reframed the impact of the bereavement process in order to minimize their experience of loss. For example, they reported the following: “I would think about all of the positive patient miracles I was involved in at work” and “I felt like I was the right person there at the right time and I was doing the best work that I could.” The participants tried to focus on the positive aspects of their work, such as all of the care that they provided to patients and their families, the positive impact of their daily interactions with them, and the meaning and value of their work, which helped healthcare providers to nurture their inner strength and resilience (Chen et al. Reference Chen, Chow and Xu2023; Conte Reference Conte2011; Granek et al. Reference Granek, Barrera and Scheinemann2016; Groves et al. Reference Groves, Adewumi and Gerhardt2022; Hogan et al. Reference Hogan, Fothergill-Bourbonnais and Brajtman2016; Shimoinaba et al. Reference Shimoinaba, O’Connor and Lee2014; Wenzel et al. Reference Wenzel, Shaha and Klimmek2011).
Behavioral coping
Behavioral coping involved escape from death, social communication, and carrying out routine activities. Grief is a painful experience, and healthcare professionals may actively ignore and avoid death (Betriana and Kongsuwan Reference Betriana and Kongsuwan2019, Reference Betriana and Kongsuwan2020; Granek et al. Reference Granek, Mazzotta and Tozer2013; Zhang et al. Reference Zhang, Cao and Su2022). Some participants expressed an unwillingness to discuss patient deaths. They reported that they chose not to enter a patient’s room and had even hidden themselves in order to avoid situations that required them to provide death care.
Social communication was divided into formal debriefing and informal communication. Formal debriefing refers to debriefing meetings at which the participants had an opportunity to express their experiences and feelings, so that they could communicate and connect more closely with team members (Bacon Reference Bacon2017; Hogan et al. Reference Hogan, Fothergill-Bourbonnais and Brajtman2016; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021, Reference Shimoinaba, O’Connor and Lee2014; Shorter and Stayt Reference Shorter and Stayt2010; Wenzel et al. Reference Wenzel, Shaha and Klimmek2011; Wolfe et al. Reference Wolfe, Hinds and Arnold2022). Informal communication describes situations in which the participants were able talk with peers (Bacon Reference Bacon2017; Betriana and Kongsuwan Reference Betriana and Kongsuwan2020; Chen et al. Reference Chen, Chow and Xu2023; Chew et al. Reference Chew, Ang and Shorey2021; Conte Reference Conte2011; Granek et al. Reference Granek, Barrera and Scheinemann2016, Reference Granek, Mazzotta and Tozer2013, Reference Granek, Nakash and Ariad2019; Groves et al. Reference Groves, Adewumi and Gerhardt2022; Hinderer Reference Hinderer2012; Hogan et al. Reference Hogan, Fothergill-Bourbonnais and Brajtman2016; Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018; Mirwald Reference Mirwald2019; Morrissey and Higgins Reference Morrissey and Higgins2021; Nagdee and Andrade Reference Nagdee and Andrade2022; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021; Shorter and Stayt Reference Shorter and Stayt2010; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010; Wolfe et al. Reference Wolfe, Hinds and Arnold2022; Zhang et al. Reference Zhang, Cao and Su2022), leaders (Bacon Reference Bacon2017; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021; Zhang et al. Reference Zhang, Cao and Su2022), friends (Granek et al. Reference Granek, Barrera and Scheinemann2016; Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018; Morrissey and Higgins Reference Morrissey and Higgins2021; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010), and family members (Bacon Reference Bacon2017; Chen et al. Reference Chen, Chow and Xu2023; Granek et al. Reference Granek, Barrera and Scheinemann2016, Reference Granek, Mazzotta and Tozer2013; Khalaf et al. Reference Khalaf, Al-Dweik and Abu-Snieneh2018; Morrissey and Higgins Reference Morrissey and Higgins2021; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010). Peer communication, in particular, was the most common coping strategy used by participants who shared similar work environments and traumatic experiences, and compassion, listening, and understanding were important social support resources for the healthcare professionals.
Daily routine activities were viewed as opportunities for relaxation and also a positive coping strategy used by the participants. These activities included periods of rest, hobbies, shopping, exercise, vacations, and spending time with family, all of which helped the healthcare professionals to alleviate stress and reduce negative feelings (Chen et al. Reference Chen, Chow and Xu2023; Granek et al. Reference Granek, Barrera and Scheinemann2016, Reference Granek, Mazzotta and Tozer2013; Hogan et al. Reference Hogan, Fothergill-Bourbonnais and Brajtman2016; Mateo et al. Reference Mateo, Carlos and Chua2020; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Treggalles and Lowrie Reference Treggalles and Lowrie2018; Wenzel et al. Reference Wenzel, Shaha and Klimmek2011; Wolfe et al. Reference Wolfe, Hinds and Arnold2022).
Relational coping
Boundary-setting and relationship termination activities were common relational coping strategies used by the healthcare professionals. Boundary-setting, which is a defense mechanism, helped them to maintain an appropriate psychological distance from patients and their families, and to resist the onslaught of distressing emotions. This strategy was effective in helping physicians and nurses to carry out their work and to cope with their bereavement experiences (Anyadike Reference Anyadike2014; Granek et al. Reference Granek, Barrera and Scheinemann2016, Reference Granek, Mazzotta and Tozer2013, Reference Granek, Nakash and Ariad2019; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997; Treggalles and Lowrie Reference Treggalles and Lowrie2018). Relationship termination activities included attending funerals, writing letters, and conducting follow-up interviews, which were considered to be effective coping strategies for healthcare professionals to help them to manage feelings of loss (Morrissey and Higgins Reference Morrissey and Higgins2021; Rashotte et al. Reference Rashotte, Fothergill-Bourbonnais and Chamberlain1997).
Spiritual coping
Spiritual coping strategies mainly involved the spiritual beliefs of the individual, including their religious and non-religious beliefs. The participants expanded their spiritual strength through use of religious statements and prayers, and religious-based support helped them to cope with patient deaths (Betriana and Kongsuwan Reference Betriana and Kongsuwan2019; Chew et al. Reference Chew, Ang and Shorey2021; Conte Reference Conte2011; Mirwald Reference Mirwald2019; Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021; Wenzel et al. Reference Wenzel, Shaha and Klimmek2011). For example, the healthcare professionals reported the following: “God has helped me through this” (Gerow et al. Reference Gerow, Conejo and Alonzo2010), “I think that praying and reading the Bible can support and inspire you, to some extent” (Nagdee and Andrade Reference Nagdee and Andrade2022), “Give my nerves to God” (Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021), and “Religion is very important to me; it helps me to accept the inevitability of death and dying” (Yang and McIlfatrick Reference Yang and McIlfatrick2001). Furthermore, some participants, though not religious, had their own belief systems, inner voices, and internal hopes, and their spirituality and faith helped them to cope with patient deaths (Anyadike Reference Anyadike2014; Granek et al. Reference Granek, Barrera and Scheinemann2016, Reference Granek, Mazzotta and Tozer2013).
Occupational coping
Three occupational coping strategies were identified: providing optimal care, reflection on career roles, and shift in career goals.
Providing optimal care to dying patients was a coping strategy used by nurses after they had experienced the loss of a patient, and it involved comforting and respecting the patient, equal caring, compassionate care, and selfless love (Anyadike Reference Anyadike2014; Conte Reference Conte2011; Granek et al. Reference Granek, Barrera and Scheinemann2016; Mateo et al. Reference Mateo, Carlos and Chua2020; Yang and McIlfatrick Reference Yang and McIlfatrick2001).
Professional bereavement also caused healthcare professionals to reflect on their professional roles. While novice nurses struggled with professional bereavement and even questioned their job role (Morrissey and Higgins Reference Morrissey and Higgins2021), they recognized that dealing with bereavement was part of a nurse’s job (Thompson et al. Reference Thompson, Austin and Profetto-mcgrath2010). Some experienced participants believed that they could still provide meaningful care to their patients’ families, even when no cure could be found, which helped them to find a sense of meaning in their role as nurses (Conte Reference Conte2011). In addition, they also felt that it was crucial to learn about the value and complexities of the profession through bereavement (Mirwald Reference Mirwald2019; Wolfe et al. Reference Wolfe, Hinds and Arnold2022).
Shifting to different career goals was also identified as an occupational coping strategy. Some healthcare professionals claimed that if they had sufficient knowledge and skills, their patients could have been saved (Betriana and Kongsuwan Reference Betriana and Kongsuwan2019; Chen et al. Reference Chen, Chow and Xu2023), and they used the following expressions to describe their feelings: “should have done more” and “if we had sufficient knowledge of these technologies, the patients could have been saved.” These beliefs made them more motivated to develop their medical knowledge. However, some medical professionals recognized the limitations of medicine and set more realistic goals for their careers (Chen et al. Reference Chen, Chow and Xu2023). Other participants noted the necessity of inner strength, which helped them to adopt a gentle and assertive approach to their nursing work, so as to better support their patients’ families through the grief process (Shimoinaba et al. Reference Shimoinaba, McKenna and Copnell2021).
Discussion
This systematic review examined 30 qualitative studies of the coping strategies used by healthcare professionals who had experienced the loss of their patients, and 6 different coping styles were identified. The findings confirmed the multidimensional and unique coping strategies used by healthcare professionals when they experience bereavement. This manuscript not only contributes to deepening our understanding of this phenomenon, but also provides a framework for designing appropriate interventions to help healthcare workers to respond more effectively. Therefore, this study could be used to provide a basis for evidence-based practice.
Consistent with extant literature describing the field of professional bereavement coping, our findings support the use of a variety of coping styles by healthcare professionals. In contrast to Zheng’s study which focused on internal and external resources, we concentrated on the coping strategies themselves and examined multiple dimensions. In addition, distinct from the coping strategies proposed by Crunk, our review also identified the form of occupational coping, which can be understood as a specific coping style used by healthcare workers when they experience professional bereavement.
Emotional coping involves emotional catharsis and emotional detachment. Similar to Zheng’s results, healthcare professionals use crying as a mechanism of emotional release. Unlike crying in response to grief, the crying of healthcare professionals during the coping process is a conscious emotional release. In addition, healthcare professionals also use detachment as strategies to manage their emotions. There are 2 main reasons for this. First, healthcare professionals engage in multiple roles when providing bereavement care: they offer patient-centered and family-centered care, and are simultaneously advocates and communication mediators (Raymond et al. Reference Raymond, Lee and Bloomer2016). They have to manage their emotions as effectively as possible in order to remain rational, and in a position to perform their professional duties. Second, healthcare professionals are obliged to learn how to conceal their emotions because invisible rules about emotional displays control the extent to which care providers can outwardly express their emotions (Brighton et al. Reference Brighton, Selman and Bristowe2019). Emotional responses are often regarded as a sign of weakness, and care workers often feel that they have to suppress their emotions until an appropriate moment to grieve presents.
In terms of behavioral coping, almost all studies have shown that healthcare professionals actively cope by means of self-activities (rest, hobbies, shopping, sports, vacations), social interactions (peer interactions, friend interactions, family interactions), and organizational support (debriefing, leader support), which highlights the importance of behavioral coping strategies. Through these remarkable activities, individuals are able to release stress and reinvest in a meaningful life, which is consistent with Zheng’s research (Zheng et al. Reference Zheng, Lee and Bloomer2018). In addition, we identified avoidant coping strategies as a response to patient deaths. Although this coping style is uncommon, it reflects how helpless some people can feel when they are confronted with bereavement. Personality has an important influence on bereavement coping, and professionals adopt different coping styles to deal with death at work. This underscores the need to help individuals to cope effectively, while taking into account their unique personalities and experiences.
In clinical practice, death involves the loss of a close relationship with a particular patient with whom one has shared part of a significant journey, and this means that healthcare professionals inevitably come to adopt relational coping strategies. On the one hand, they may isolate themselves from the relationship by setting boundaries; that is, they set boundaries at work and consciously distance themselves from the patient and their family. Therefore, healthcare organizations should pay close attention to any disengagement behaviors exhibited by their healthcare staff, and provide timely support. On the other hand, healthcare professionals may also end the relationship formally, by attending funerals and writing letters. Traditionally, participating in a funeral provides an opportunity to “say goodbye,” signaling the end of the relationship (Burrell and Selman Reference Burrell and Selman2020). However, the included studies noted that some participants expressed uncertainty about attending funerals and were unsure when or if they should separate from their patients’ families (Granek et al. Reference Granek, Mazzotta and Tozer2013). This highlights a need for future research to examine the attitudes and practices of healthcare professionals toward attendance at their patients’ funerals.
While a spiritual reaction may take the form of “question of religion” (Chen and Chow Reference Chen and Chow2021), spiritual coping is an important method for healthcare professionals, as it allows them to utilize their own spiritual resources to cope with bereavement and it is to some extent an effective protective strategy. This review found that most participants utilized religious beliefs and individual philosophical beliefs to transcend themselves, draw strength, and find meaning in their lives. Charzyńska defines spiritual coping as an attempt to overcome stressors based on transcendence, which is categorized into 2 types of coping: positive coping and negative coping (Charzyńska Reference Charzyńska2015). Positive spiritual coping addresses difficult situations by resorting to meaning-seeking, focusing on moral values and religion. A study (Soola et al. Reference Soola, Mozaffari and Mirzaei2022) showed that positive spiritual coping was the main coping method used by medical staff. Given the prevalence of spiritual coping practices in healthcare settings, it is helpful for hospital managers to offer spiritual coping workshops to enhance the spiritual values of their staff members and promote the adoption of positive spiritual coping strategies.
It is noteworthy that we recognized some new codes when examining the coping strategies of healthcare professionals, namely, occupational coping. The experience of bereavement is an opportunity for professional growth and it promotes reflection on the meaning of job roles and goals. As Chen et al. (Reference Chen, Chow and Xu2023) suggests, the professional bereavement coping process is driven by the meaning that participants attribute to the death of a patient. They can find role meaning, gain inner strength, and achieve fulfillment in the care that they provide to their patients. Furthermore, this coping strategy is a transformative process. Similar to the findings of a recent study (Arantzamendi et al. Reference Arantzamendi, Sapeta and Belar2024), coping with bereavement is an iterative and dynamic process that evolves with clinical experience. This also suggests that hospital managers should pay attention to key elements of the coping process to help healthcare professionals find meaning and promote personal growth and intrinsic value.
The synthesized results provide a basis for improving the bereavement coping skills of healthcare professionals. Among the existing studies focusing on the bereavement coping skills of professionals, the Self-Competence in Death Work Scale developed by Chan et al. (Reference Chan, Tin and Wong2015) focuses on both emotional and existential coping dimensions. Our findings support a multi-faceted perspective of professionals’ coping skills to develop targeted intervention programs and help healthcare workers to deal with grief and loss effectively. In addition, medical administrators can determine the coping practices of their medical personnel by evaluating these 6 dimensions, so as to provide multi-faceted coping resources to improve their coping strategies and promote individual and professional growth. Furthermore, although we identified several coping strategies used by healthcare professionals when they experience the loss of a patient, the literature suggests that certain forms of coping are akin to a double-edged sword. For example, setting boundaries is a common coping strategy, and on the one hand, it can help healthcare professionals to maintain an appropriate distance and continue to work effectively. On the other hand, high levels of death anxiety among healthcare professionals may stimulate the use of avoidance as a coping strategy, which can lead to poor job performance and a decline in individual health (Nia et al. Reference Nia, Lehto and Ebadi2016). Thus, it is crucial to develop a professional bereavement coping strategy scale in order to assess the coping strategies used by healthcare professionals and examine the relationship between personal coping strategies and outcomes.
Limitations
It is important to acknowledge several limitations of this systematic review. First, the review only included studies published in English. Coping strategies for professional bereavement may differ across cultures, which means that we might have missed some perspectives and evidence from publications in other languages. On the other hand, gray literature was not included in this review, which may have led to bias. Furthermore, like other qualitative reviews, this manuscript might be influenced by the subjective perspectives of the authors.
Conclusion
This review synthesized 30 qualitative studies involving 545 participants during the period from 1997 to 2022, reporting on the coping experiences and strategies of professional bereavement among healthcare practitioners, and 6 coping strategies were identified. It highlights the inevitability of healthcare professionals experiencing bereavement and the multidimensional nature of their coping styles. Healthcare professionals can use positive reframing to help them cope with the loss of a patient, give meaning to their job roles, transcend themselves, and gain inner strength. Healthcare administrators can also focus on the bereavement coping process by exploring the 6 strategies, enhancing bereavement coping skills, and improving the quality of bereavement care by providing bereavement education, spiritual coping workshops, and organizational support for medical staff.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951524001147.
Competing interests
The authors declare that there is no conflict of interest.
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