Good grief: Staff responses to childbearing loss

Introduction 

Health care providers’ difficulty in handling the painful emotional content of their work continues to challenge both clinicians and educationists. This observation may engender disbelief and disappointment, especially 30 years after the finding that staff are ‘flung apart’ by childbearing loss, and are able to show only ‘aversion and silence’ (Bourne, 1979, p. 59). My observation, though, is supported by research showing the continuing existence of ‘denial within the profession’ (Cowan and Wainwright, 2001, p. 314) and ‘a conspiracy of silence’ surrounding staff’s emotional responses (Redinbaugh et al., 2003, p. 188). Such pain is not only disturbing for the staff member, it also brings the potential for a lower standard of care (Cowan and Wainwright, 2001). The work of these two groups of authors indicates the trickle of research seeking to address this most sensitive of sensitive professional issues. In this paper, I contemplate the extent to which research has been able to illuminate these professional sensitivities. It emerges that, as Bourne identified, this area has attracted woefully little research or other attention.

An exception to this lack of attention, though, is found in the work of Nallen (2007), although her main focus was on the midwife’s support for grieving parents. Further, a qualitative study (Cowan and Wainwright, 2001) explored the impact of a baby’s death on the midwife. While this study identified the midwife’s unresolved grief, lowered self-esteem and isolation, which verge on post-traumatic stress disorder, the findings relate mainly to organisational issues. Such issues include the likelihood of litigation (Symon, 1998).

Because of the limited attention to maternity staff grief, I must, throughout this paper, apply the findings from other better-researched areas to perinatal care. To investigate this topic, I searched the literature using the databases CINAHL, Medline and Web of Science. The search terms were perinatal death, pregnancy, crying, hospital, grief and staff. The scarcity of relevant items required me to follow up the references within each item.

In order to explore the crucial developments in research into staff grief, it is necessary, first, to differentiate two distinct but overlapping phenomena. Crying is not infrequently a manifestation of grief, but it must be distinguished from grief itself, of which crying is but one symptom. To demonstrate this distinction, I draw on research which has addressed staff grief and make comparisons with other studies focussing specifically on staff crying. This distinction raises issues which have been shown to affect staff crying, staff grieving or both. These issues demonstrate the importance of education, comprising both undergraduate and continuing education.

I use the term ‘staff’ to denote a range of personnel who provide clinical care, irrespective of discipline, qualification or status.

Crying 

In her Turkish-based survey to identify factors associated with crying, Kukullu and Keser (2006) demonstrated that crying is culturally-influenced, even culturally-determined. This cultural influence is apparent in the frequency of women crying in Turkey, which reaches an average of 3.5 occasions in 4 weeks (2006, p. 426). Along with North Americans, Turkish women report the highest frequency of crying (Vingerhoets et al., 2000, p. 367). This high frequency emerges despite Turkish women’s reluctance of to cry publicly for fear of being labelled pathetic.

The gendered nature of crying is well-recognised (Carmichael, 1991), with a tendency for women to cry oftener, longer and harder than men (Vingerhoets et al., 2000). Gender differences, though, may not be as clear cut or immutable as at first appear. For example, a footballer crying would once have been unthinkable. In a western European culture, tears of emotion are permissible for men at births and deaths. Crying at Turkish funerals is strictly controlled, being permitted, even encouraged, only before the interment or afterwards (Kukullu and Keser, 2006). Turkish women also weep prior to a wedding or when a male relative leaves for military service.

Kukullu’s examples show the strong association between crying and sorrow. Becht and Vingerhoets (1997 cited in Vingerhoets et al. (2000)) showed that, for women particularly, crying is linked with five emotions; as well as sadness, these include, anger, frustration, fear and powerlessness. Vingerhoets, however, later interpreted the crying-related ‘emotionally charged settings’ (2007, p. 341) more broadly. These need not be negative events, but include happy occasions such as reunions.

The authoritative definitions of crying (Vingerhoets et al., 2000, Vingerhoets et al., 2007) emphasise the excretion of tears, with changes in facial expression, vocalisation and breathing. Simultaneous changes in bodily muscle tone give rise to racking sobs. An often ignored feature is the eyes reddening prior to actual crying; although this phenomenon was noted and misattributed by Darwin:

crying is a release for eyes over-engorged with blood by excessive emotion (Darwin, 1872, p. 165).

Crying and grief 

Thus crying as an expression of grieving a loss through death may actually be encouraged within cultural constraints. Since the somewhat flawed research by Borgquist, grief has been reported as a major mood state giving rise to crying in adults (Borgquist, 1906). Crying in infants, however, is a crucial form of communication, which has some features in common with adult crying (Vingerhoets et al., 2000, p. 355). Thus, crying through grief has been identified as but one way of seeking helpful support. Such community-based supportive behaviour is recognised as mourning, during which all affected by the loss, either singly or as a group, contemplate the meaning and implications of the death. In western society, these group activities are recognised as usually occurring at funerals and wakes.

The act of crying in company, therefore, is a form of mourning which elicits support. This contention is supported by the underlying psychological rationale for crying being attributable to ‘perceived helplessness’ (Miceli and Castelfranchi, 2003, p. 268). Thus, mourning is a companionable expression of grief, to be differentiated from the solitary forms of crying which, being unsupported, lack comfort:

Weeping alone is painful. Grief is most powerfully eased when it can be shared (Carmichael, 1991, p. 107).

Crying caused by the pain of grief, though, is not straightforward. The complex emotions recognised as grief are well-reported. A usefully alliterative mnemonic summarising these complex interactions links regret, reproach and relief (Macdonald, 1964). On the basis of this summary, it is hardly surprising that for many bereaved people, guilt compounds the emotional turmoil.

An anecdotal account of crying among one group of hospital personnel, usefully distinguishes types of crying (Angoff, 2001, p. 1017). The ‘good cry’ is for the patient, including grieving, which may be appreciated by grieving relatives (Alexander, 2001). A ‘bad cry’, on the other hand, is for the person themselves, possibly under excessive negative stress. Angoff forgets, though, that ‘good’ and ‘bad’ may merge when care for the dying or grieving is compromised by, for example, organisational factors (Mander, 2000, p. 46).

Societal changes making it more difficult for a grieving person to express their loss through tears have been deprecated (Durston, 1998). He attributes such suppression to the demise of death ritual and the accompanying unhealthy relationships, originally highlighted by Gorer (1965). Gorer’s writing was appropriate to a country recovering from cataclysmic conflict. His comparison of death taboo with the Victorian sex taboo suited a society about to embark on the ‘swinging sixties’. We should question, though, whether the recent displays of mass mourning over certain nationally publicised events reflect more than the popular media choreographing public behaviour. Perhaps the ‘one size fits all’ approach to grief, which Gorer regretted, has been overtaken by healthier attitudes to expressing grief through crying. Thus links between crying and grief may be becoming more firmly established.

Staff grief 

On the basis of these thoughts on crying and grief, the distinction between these phenomena appears artificial to the point of futility. This distinction may matter in the present context, though, because of somewhat warped ideas about professional behaviour, as reported by Angoff:

Physicians have been taught to keep an emotional distance lest they lose the objectivity needed to treat patients successfully (Angoff, 2001, p. 1018).

Hence, I address staff grieving before considering staff crying.

Health care professionals’ grief was investigated by American researchers (Redinbaugh et al., 2001), who linked grief with burnout to identify effective coping strategies. They conclude that occupational choice crucially underpins the way the various staff groups grieve patient deaths differently. This work’s useful insights into staff experiences is limited by focussing on professionals working with the terminally ill.

Perhaps attempting to address this criticism, Redinbaugh led another team to study the emotional reactions of staff to the death of an ‘average patient’ (sic) (Redinbaugh et al., 2003). Data were collected qualitatively and quantitatively from 188 staff, comprising different grades of un/qualified medical staff caring for 68 patients. The emotional impact of the death, varying from moderate to very disturbing, was unrelated to grade. Junior staff, however, perceived significantly greater need for emotional support. Unsurprisingly, female staff reported increased distress and more symptoms of grief and use of healthy coping resources than males.

More relevant is Baverstock and Finlay’s study focussing on paediatric registrars’ emotional responses to child death (Baverstock and Finlay, 2006). The response rate (75%) to a self-administered questionnaire indicates the perceived importance of this topic. These researchers were particularly concerned with the availability of ‘debriefing’, although this term was not defined precisely (Alexander, 1998). The respondents’ debriefing experiences, though, were not invariably positive; some had experienced a ‘finger pointing exercise’ or involving too many ‘strong personalities’ (2006, p. 774) . The involvement of 15–20 people in a debriefing group may explain this. The intensely personal implications of a death emerge, especially if the child died at Christmas or if staff made comparisons with their own children.

In her commentary on the Baverstock and Finlay paper, Reynolds (2006) outlines the strategies which medical personnel stereotypically use to deal with their emotional responses to child death. She observes that some may ‘externalise’ the problem, presumably in an effort to distance themselves from the raw emotion (2006, p. 727). Others are said to become ‘a little numb’ (2006, p. 727). Reynolds draws attention to the medical use of humour, sometimes known as ‘gallows’ humour, which disconcerts outsiders. Emotional support is a strategy traditionally provided by senior medical colleagues. Changing working patterns, though, make this less likely, leaving ‘senior nurses’ (2006, p. 727) to support colleagues of all disciplines as well as the families.

Another team of American researchers attempted, because of its serious implications for the quality of care, to investigate the grief of long-term carers in the community (Rickerson et al., 2005). A questionnaire survey of staff symptoms of grief again produced a high response rate (86% n = 203) from the twelve staff groups approached. The responses showed a wide variation in the number and type of symptoms experienced. Only a few staff were either minimally or not affected. The more recent deaths were found to be associated with more symptoms. The most recent death was said by 91% of the respondents to have affected at least one domain of grief, such as the staff member’s emotional state or their relations with other patients. The staff’s widespread use of informal sources of support was identified and a large majority of staff stated that they would welcome support from the employing organisation, such as a memorial service. Contrary to Reynolds’ anecdotal assertion about medical staff’s coping strategies, Rickerson and her colleagues found that the more experienced were likely to encounter more symptoms of grief. These researchers question whether a cumulative effect might be operating.

Staff crying 

The issue of crying among staff in hospitals has attracted considerable attention in the North American literature. This attention is largely due to medical students’ much-publicised perceptions of their mistreatment in clinical settings, which fit Angoff’s classification of a ‘bad cry” (2001, see above). The responsibilities which qualified staff carry, though, lend crying a quite different significance. This significance emerged in the words of the midwives I interviewed in a qualitative study of the care of the woman who does not have her baby with her (Mander, 1995, Mander, 2006). Although the midwives were generally comfortable with crying with a grieving woman, they were less sanguine about the implications of their crying for their care. In order to prevent their care being adversely affected, the midwives told me of their need to control their crying:

Effie: I think it is fair enough for you to be grieving along with her as long as you are in control of the situation ... I think it maybe quite a good thing for (the mother) that someone is there sharing the grief, so long as (the midwife) is aware of what she is doing herself. I think there is a situation where you can be upset along with someone but still remain professional.

The midwife’s ultimate aim of supporting the woman or the couple was clearly at the forefront of their thoughts:

Ottily: You can always cry with the couple. I think that the important thing is for you to be strong in order to be able to help them.

Some of the midwives told me that being able to cry while continuing to provide effective care was facilitated by the midwife’s self-knowledge:

Leonie: I think there has to be (limits), we have to know where they are, and maybe if we are getting to that stage or feel it’s getting too much then we have to stop short because then we stop being any help. We stop being the pillar of support that the mother so desperately needs.

Such self-awareness was thought to enable the midwife to remove herself from a caring situation if there was a danger of care becoming counter-productive:

Kay: Obviously if you feel that it’s upsetting her, then that is the time to withdraw, and just leave them on their own and get yourself together.

The midwife’s leaving the caring situation would clearly have short term staffing implications. There might also be longer term effects:

Leonie: Maybe she can take time out ... if there’s two midwives then it’s easier ... the midwife then needs to go and talk it over with one of her fellow colleagues, get out her emotions about it … she can’t bottle it up herself or I think she’d probably go off (duty) feeling very depressed and maybe not handle the next one quite so well ...

Crying in hospitals was the focus of a quantitative study undertaken in Sydney, Australia and which contributed to a larger multidisciplinary cross-cultural project (Wagner et al., 1997). The questionnaire was developed from staff reports of critical incidents involving crying. The sample was opportunistic and, due to medical practitioners’ low response rate (33% n=52), somewhat unbalanced. The response rates for the nurses and medical students were 55% and 99% respectively.

Unsurprisingly, the women respondents reported a significantly higher rate of having cried than their male counterparts (67% versus 28%). The group who were most likely to have cried were the female nurses (79% n=96) compared with the male medical students being the least likely (19% n=52). Perhaps because of the quantitative nature of the study Wagner and her colleagues did not ask how comfortable or uncomfortable the respondents felt with having cried. The answer to this question, however, may be observed in the response rates among the three groups, already mentioned.

Culture featured in at least one way in this project. It emerged quite explicitly in the tendency of the nursing staff to take their work problems to colleagues and supervisors. The medical culture, though, meant that neither medical practitioners nor students sought support within their workplace, resorting to friends and family for solace.

The Austrian stage of this study produced findings similar in many ways to the Australian work (Barth et al., 2004). The respondents in Austrian hospitals were generally marginally less likely than their Australian equivalents to ‘allow’ health workers to cry. Whereas in Australia the number of staff who would be comforted when crying was 65% of nurses, 52% of medical practitioners and 44% of medical students, in Austria the figures were 47%, 19.2% and 20% respectively. The number who encountered a negative reaction in Australia was 2.5% of nurses, 9% of medical practitioners and 21% of medical students, in Austria this applied to 6%, 6% and 4% respectively. While both Wagner et al and Barth et al argue that medical staff suffer from the hospital culture, it may be that the picture is not quite as clear cut as they suggest.

Both the Austrian study and the Australian study considered the reason for the staff member crying, such as organisational issues or loss/death related sorrow. These reasons clearly fit Angoff’s definition of ‘good’ and ‘bad’ cries, as mentioned above. It is not clear, though, how or whether the researchers managed to define the extent or degree of the crying. This distinction, to which Miceli and Castelfranchi refer (2003), implies a process continuum reflecting different levels of intensity of crying. These range from crying, through weeping, sobbing, sniffing and sighing, to brimming or reddened eyes. These authors dismiss these variations on the grounds of culture and personality, but perhaps they matter more than that. The importance of these distinctions emerged in my own research when the midwives were at great pains to clarify the extent of crying which they regarded as acceptable. This point was made unambiguously:

Kay: I think there’s crying and crying. And there’s a few tears and having the screaming abdabs.

Irene: I have cried many times. I don’t totally break down,… but I would certainly shed a tear or two.

The rationale for this distinction was explained by a more experienced and confident midwife:

Annie: I must admit I am quite an emotional person myself and obviously you don’t want to get hysterical or anything like that. I’ll be quite honest – I can’t help myself shedding a few tears. You just have to make it very quiet and discrete and not ... You don’t want them having to feel sorry for you, which would obviously be totally inappropriate ...

Still with the importance of providing effective care at the forefront of her mind, another midwife explained:

Kay: The last thing the mother needs is to be comforting somebody who is supposed to be helping her. But I don’t think that a moist eye or a tear running down my cheek is going to do her any harm.

Vingerhoets and colleagues (2000) question whether the distinction, such as the midwives made, between different forms of crying is real. Williams and Morris (1996), on the other hand, concur more with the midwives by differentiating at least two forms. On the basis of their study of Israeli and British adults, Williams and Morris, first, identify a serious form of crying, which is long lasting and not easy to control. Such serious crying interferes with other actions and affects those nearby – having a generally negative effect. The other type of crying identified by these researchers is much more variable in its manifestation. It tends not to disrupt other activities and is more easily controlled. It is likely that the crying described by the midwives I interviewed corresponds with the latter form.

Discussion 

Although some staff appear to have quite a clear perspective on the place of crying in clinical situations involving grief, others have been shown to be less sanguine in this respect. In view of the potential for such discomfiture to adversely affect interaction with grieving parents and thus jeopardise the quality of care, it is necessary to consider how this awkwardness might be remedied.

The opinion piece by Angoff recounts the traumas which medical students may encounter at the hands of their ‘medical educators’ (2001, p. 1018). She calls for an acknowledgement that it is:

not only okay to cry, but it is understandable, appropriate and sometimes desirable (2001, p. 1018).

Writing for an audience of medical practitioners, she argues for an end to the tendency to ignore sadness, irrespective of whether it is found in patients, students or ourselves. Thus, as mentioned by others (Wagner et al., 1997, Redinbaugh et al., 2003) on the basis of their empirical studies, the place of changes in the education system begins to emerge.

In their study of paediatricians’ emotional responses, Baverstock and Finlay (2007) asked about the registrars’ preparation for communicating with grieving parents. While Baverstock and Finlay considered that learning from ‘seeing it done’ (2006, p. 775) was most effective the registrars, paradoxically, stated that they were invariably alone in these challenging situations. For this reason any opportunity to learn from others was thwarted. Commenting on Baverstock and Finlay’s original paper, Reynolds (2006) regrets that the loss-related training for medical practitioners concentrates on the documentation, rather than the emotional component. She notes that ‘senior nurses’, who tend to be less embarrassed, may provide support for medical staff, but does not go as far as suggesting that nurses may fulfil an educational role. Reynolds advocates that the Child Bereavement Trust may offer education to assist staff coping with distressing encounters.

Thus, improved education, either at an undergraduate level or as a component of continuing professional development, would appear to be necessary. Fortunately this learning may also happen in the clinical setting. The data suggest that the more senior medical personnel are not invariably the most effective role models and that support is sought and obtained from a number of sources. As well as support being shared with medical staff, it may be that nurses, midwives and medical practitioners may also learn from each other.

Conclusion 

It is important that, especially during childbearing, staff should be able to engage healthily with clients and patients and their families. In this way staff will be more likely to provide an appropriately high standard of care at this most sensitive and crucial of times (Cowan and Wainwright, 2001). Part of this engagement involves, if and when necessary, the staff being able to express their sorrow in a way with is culturally, occupationally and personally appropriate.

The research in the area of staff responses to loss in childbearing is disappointingly scarce. It is therefore necessary to apply research from other areas of care to childbearing loss. The research which has been accessed applies to many grades of staff and many different disciplines. Some of these staff have been found to be uncomfortable or have difficulty with either their own grief reactions as expressed by crying or with others’ expressions of grief.

Perhaps a general change in culture is happening, albeit at a disconcertingly slow rate. In the absence of speedier culture change it is necessary to, first, open up this topic to more general discussion and research. Second, attempts may be made to facilitate culture change in the ‘caring professions’ by the introduction of educational interventions as part of undergraduate programmes and also in continuing professional education or development (Rich, 2002). Third, because the usual hierarchical assumptions have been shown to be particularly irrelevant in this context; it may be necessary for those who are less comfortable with explicit emotions to learn from those who are more comfortable.