Leading through COVID-19: understanding and supporting grief and loss

Ethan Kutanzi, Kathleen Fraser, MC, and Debrah Wirtzfeld, MD

 

https://doi.org/ 10.37964/cr24737

 

 

The COVID-19 pandemic has created an environment in which grief and loss are being experienced collectively. This grief can lead to increased burnout, decreased productivity, and increased likelihood of job turnover. With health care workers already facing increased risks because of their frontline pandemic responsibilities, it is important to provide leaders with knowledge and tools to support their grieving team members. Understanding the Kübler-Ross grief model, as well as grief-related concepts such as anticipatory grief, disenfranchised grief, moral injury, and complicated grief, will help leaders provide normalizing support. This approach may include building and fostering trusting relationships, engaging in self-reflection, participating in supportive conversations, and, when appropriate, sharing information around grief-support resources. There is no universal timeline for the resolution of grief; mental health impacts can last for many months and can continue to resurface for years. During the COVID-19 pandemic, we educated health care workers around the issues of grief and loss by focusing on the relationship side of the Wheel of Change, interviewing people with expertise in the area, holding town hall meetings, and hosting online “coffee and chat” sessions for physicians. We recommend relying less on policy development and, instead, focus on strengthening workplace relationships and creating opportunities for connection and discussions.

 

KEY WORDS: COVID-19, grief, leadership, support resources, Kübler-Ross, leading during COVID-19

 

CITATION: Kutanzi E, Fraser K, Wirtzfeld D. Leading through COVID-19: understanding and supporting grief and loss. Can J Physician Leadersh 2021;7(3):118–124. https://doi.org/ 10.37964/cr24737

 

“We can’t work on [it]; it works on us,” Sigmund Freud said, speaking of grief.1 No matter where or who we are, all of us experience grief. When speaking about grief and loss, we often think of death, but grief encompasses much more than reactions to death. Grief is the “normal and natural reaction to any type of loss.”2 Whether that loss be the death of a loved one, the disappearance of one’s customs or traditions, or changes to daily routines, it triggers many emotions that affect our well-being in multiple ways. Because of its enduring presentation, grief can feel bigger than our efforts to manage it.3 In addition, given its individualistic presentation, we will perceive our own loss as the worst.4 The process of grieving often provides support as we endeavour to integrate the loss (and change) we have experienced into our new normal.5 As we grieve, we may look to find meaning in the relationships or experiences that we have lost.4,5 This meaning-making, which is now suggested as an additional sixth phase in the Kübler-Ross model, can fuel personal growth toward a place of strength and resilience.5,6

 

Grief doesn’t stay contained within one’s personal space; grief comes to work with the griever.7 If a grieving worker does not receive support, they will have an increased chance of experiencing “compassion fatigue,… increased burnout, absenteeism, decreased productivity, and increased likelihood for turnover.”7,8 With health care workers already facing increased risk of these variables in the work environment,9 it is prudent to provide leaders with knowledge and tools to support grieving team members. In this paper, we explore the components of grief that health care workers may encounter and how leaders can effectively support those they lead during this challenging time. Top

 

Shining a light on the grief experience — important foundational considerations for leaders

 

The Kübler-Ross grief model

As described by Kübler-Ross, grief has five stages: denial, anger, bargaining, depression, and acceptance.4 A depiction of what these might look like in a pandemic can be seen in Figure 1. It is important to remember that these stages are non-linear and not everyone is in the same phase at the same time.4,10

 

Denial presents as a lack of acceptance of the loss. Anger may be toward others, oneself, or a spiritual being. When bargaining, the griever may experience regret and ask themselves “what if” statements. Bargaining can also involve negotiations with a “higher power.” Depression can present as sadness, emptiness, loss of motivation, and, at its extreme, suicidal ideation. Acceptance refers to the griever’s awareness that although the loss has occurred and had an impact, the griever will be okay. David Kessler, who worked with Kübler-Ross, later added one additional phase to this model: finding meaning.6 For Kessler, this refers to finding meaning in the relationship to whom or what was lost. A COVID-19 related example could be, “The quarantine brought the members of my family closer together.”

 

Application of Kübler-Ross’ grief model to COVID-19

The COVID-19 pandemic has created an environment in which grief and loss are being experienced by everyone. For some, the loss may be the passing of a loved one. For others, it may be loss of their regular routine, their job, or their social interactions. Collectively, everyone in the world is experiencing the loss of the old normal. Top

 

By applying the Kübler-Ross model of grief, we can gain insights into our reactions. Denial may present as not accepting the seriousness of COVID-19. Anger may be toward regional health authorities and the measures they have put in place, which affect our workplace. It may even manifest as displaced anger directed toward those we care for the most, be they patients, family members, or friends. When bargaining, we may say to ourselves, “If I can just go visit my friend, I won’t interact with anyone else outside of work for the next week.” Depression can present as feeling like our efforts at work are futile or in a disruption of sleep cycles. Finally, acceptance may present as the recognition that, although we can’t visit friends and family as we did in the past or interact with patients as we used to, we can find other ways to have meaningful interactions.

 

Anticipatory grief

Anticipatory grief is based on anxiety and fear for the future.10 We anticipate and start to grieve losses that have not yet happened. Our anticipated losses may be something physical — an object or person, such as a parent with a life-limiting illness. We can also anticipate the loss of future opportunities or important rituals, for example, attendance at a ceremony or event.4,5 For health care workers, anticipatory grief may sound like, “What if I am exposed and put loved ones, colleagues, and friends at risk?”5 The concept is much broader than just fear for the potential loss of a loved one. Top

 

Disenfranchised grief

Disenfranchised grief comes when our losses occur within a context that is not seen by our culture as a legitimate loss.1,2,5 It is often seen in situations where the loss and grief are not the result of death.5 For example, someone going through a divorce or family estrangement may feel that their loss does not warrant feelings of grief, as the individuals involved are still alive. Disenfranchised grief may also be relevant in situations where loss is seen to be a normal part of daily experience; in this situation, people may feel increased pressure to meet expectations that they remain professional and “keep it together.”1 This form of disenfranchised grief can be seen in the health care environment. For example, an ICU physician who experiences grief after the death of a patient may feel that their grief is minimized, or not validated, as our culture sees patients’ deaths as an expected and normal occupational experience.

 

Moral injury

Health care workers often experience moral distress, which can lead to moral injury. Moral distress may be caused by “actions…, inactions…, or other people’s actions or inactions.”11 As an example, during the COVID-19 pandemic response, moral distress can be caused when health care workers are unable to provide care to those who need it because of external factors, such as restrictions on visiting multiple care sites or lack of hospital resources to meet the needs of patients.5,12,13 Physicians might also experience moral distress when they feel compelled to work despite feeling unwell. Top

 

Complicated grief

At times, an individual’s internal capacity is insufficient to deal with their grief and they may require additional support. This presentation of grief is termed complicated grief, where the symptoms of grief interfere with one’s ability to meet the requirements of daily life for a prolonged period.14 Although grief is very individualized, there are predictors for complicated grief, including childhood adversities and a previous history of anxiety disorders.15 If leaders see team members who appear to require additional support, they can provide information and/or referrals to mental health professionals.

 

Leading our teams through loss and grief

 

Given that grief is a universal human experience, amplified during COVID-19, leaders benefit from understanding ways to approach grief and loss within their team. Discussing grief in the workplace is often avoided, which can accentuate the harm caused by the initial loss.1 Self-reflection is critical. It is tremendously important to understand our own experiences with grief, as well as our thoughts, feelings, beliefs, and biases about how to manage loss and grief.2,5,16 These crucial reflections also allow leaders to be appropriately vulnerable with their teams, which may help normalize grief by showing team members that it is an accepted and encouraged practice to ask for understanding and support. Top

 

Building and fostering trusting relationships as an integral part of our workplace culture is a proactive practice. Having these relationships firmly in place before a crisis strikes will enable grieving team members to seek “just in time” help.2,16 Through transparent and frequent communication, leaders develop team trust, which also reduces the fear and anxiety that accompanies anticipatory grief.5

 

As grief is an individual experience, every griever will exhibit different signs.2,5,17 It is important that leaders understand the complexity and variety of grief processes, so that, as team members experience them, leaders can help name and normalize them. Leaders can reference the Kübler-Ross model as a framework for potential grief responses. Grievers will demonstrate experiences that look like both progression and regression, and, at times, it might appear that grief is absent.1,16 During the COVID-19 pandemic response, it is safe to assume that almost all humans are experiencing some loss and grief.4,5 Team members acting or reacting differently than they ordinarily do may be an important indicator that they would benefit from some grief-related leadership support.

 

When engaging in grief-related support conversations, leaders may find the following principles helpful.2,4,5

• Be conscious of both privacy and safety of the space when determining where the conversation will take place.
• Allot adequate time for discussion.
• Resist the urge to problem-solve the griever’s loss during the conversation.
• Realize you are helping them by listening and creating an uninterrupted safe space.
• Be curious in your dialogue, by asking open-ended questions, such as, “Can you tell me more about that?”
• Acknowledge and validate the griever’s experience, without comparing it to your own.
• Understand that each griever is the expert in their own grief.
• Recognize that you are not a grief counsellor. Although you are providing an open space to listen, be aware of available grief support resources in your community and be prepared to share those with your colleagues early in the conversation. These supports may include those provided through medical associations, universities, or formal peer-to-peer support programs where individuals have acquired specific training around supporting peers.

 

There is no timeline for the resolution of grief. Emotional impacts can last for many months and can continue to resurface for years.1 Leaders can offer valuable support as grieving team members seek a restorative balance between processing grief and moving forward with resiliency — in other words, finding meaning. Finding meaning does not suggest that we find meaning in the death or loss. Rather, that we can find meaning in the life of, or in our relationship with, the person we lost or, in the case of non-death losses, recognize transformative opportunities to create something new. The recent COVID-19 selfie project at the University Health Network is an excellent example of this.18 The purpose of this initiative was to provide meaning by showcasing the team’s evolving strength and dedication during a challenging time as well as to commemorate the story of their service.18,19

 

In times of loss, leaders can facilitate and support their team as they navigate into a “new normal,” the re-imagination phase. Leaders can hold space for both grieving and creating, by balancing empathy for their team’s losses with inspiring hope by embracing the possibility of what comes next. Throughout this approach, leaders should adopt effective change management techniques through engagement, communication, and consistent messaging. In health care, physicians have used telehealth to increase workplace safety by ensuring that patients can quarantine and seek medical support. Some patients will want to continue with changes that were necessitated by the pandemic, whereas others will want to return to the “old way.” By sticking to the principles and guidance above, leaders will be a helping hand for both team members and patients who are navigating grief. Top

 

Our approach on educating leaders around these issues

 

Robert Gass created the Wheel of Change model as a facilitative tool to guide transformational change by considering three domains: hearts and minds, behaviour, and structure (Figure 2).20 The model emphasizes that change often requires a focus on relationships and discussion rather than a shift in policy and procedure. It demands a focus on the human side of change and evokes the principles of change management.

 

This is the approach we have focused on during the pandemic. We educated physicians around issues related to loss and grief, rather than invoking a strictly systems approach. In other words, we did not create any new policies or processes. Rather, we focused on relationship components of our environment, through interviews with grief experts in town hall meetings and virtual “coffee and chat” sessions.5

 

On 30 April 2020, a virtual conference was held where a leader with focused education and experience in grief and loss (KF) shared her knowledge through non-didactic teaching, responding with empathy as difficult questions were posed by the participants. The leadership practices outlined in this paper were reviewed and discussed in a safe setting. Because of her expertise, KF was able to be responsive to the participants’ questions. Some of the questions included: “Can you talk a little bit about loss and grief of individuals and teams when they describe feeling a sense of moral harm from not being able to care for their patients as usual?” and “Can you talk about anticipatory grief, and how leaders can support their teams when it is present?”5 The facilitator shared her own leadership vulnerabilities in addressing loss and grief with team members and this created an atmosphere that allowed the participants to feel safe in asking their own vulnerable questions. Top

 

The essential aspects of the domains of behaviour and hearts and minds represented by the Wheel of Change were used by JT Sanford in her leadership following the loss of a faculty member at JMU School of Nursing, who passed away as a result of an infection while receiving chemotherapy in 2015.16 She focused on creating an atmosphere of care and compassion.16 She dedicated time and courage to telephoning each employee individually to inform them of their colleague’s death. She also solicited the support of the university’s counseling centre. She visited classes of students who were impacted by the loss, providing opportunities to discuss feelings, as well as offer support. After the funeral service, faculty met with students and debriefed. By approaching this situation with a relationship focus, loss and grief were effectively managed and supported.

 

A leader can use the Wheel of Change model to support change during the pandemic in a way that recognizes both relationships and structure.20,21 Key considerations for each domain can be found below.

 

Hearts and minds

• Create a common purpose within teams, through open dialogue and a vision for a successful future.
• To foster a sense of belonging, allow everyone to be involved in the change process. This will include spaces for creative thinking outside regularly scheduled meetings and without structured agendas.
• Allow people to identify limiting beliefs or concerns without fear of reprisal by creating safe spaces. This may involve the use of facilitators or consultants.
• Recognize the stages of grief and support team members through active listening and early referral to resources to support grief.
• Provide education around emotions and emotional intelligence to yourself and team members.

 

Behaviour

• Establish clear norms and behaviours for how the change will take place that are accepted by everyone and support the diversity and inclusion of group members.
• Communicate widely with respect to the change by using whatever media the team agrees on.
• Be transparent in what is expected of all members of the team to reach the vision of future success. Ensure that everyone knows their role in getting the team through the pandemic and that there is adequate time to achieve goals.
• Provide a forum for bidirectional feedback through the creation of safe spaces.
• Provide adequate support in the form of mentoring, educating, and coaching.
• Provide an environment where people can “fail” and be supported in using this as a learning experience.

 

Structure

• Develop appropriate and documented strategies, including performance metrics and impact assessments, to support the vision of a successful future.
• Adequately resource and support the structures for necessary change. This will require an assessment of the role of existing structures to adequately support the change.
• Develop and implement processes that support the change initiative. This will require an assessment of the role of existing processes to adequately support change.
• Ensure that the change supports the values of the team and that core competencies are present. If additional core competencies are necessary, these must be supported.

 

Through careful consideration of each of the three domains, a leader and their team can understand and support grief and loss during the pandemic and develop a vision for a successful future. Top

 

Conclusion

 

Returning to Sigmund Freud’s words, “We can’t work on [it]; it works on us,” although we cannot work on grief, we can have effective leaders who enable the griever to progress through its stages. After first self-reflecting on the meaning and impact of grief in themselves, leaders can then turn outward and use the concepts and strategies discussed in this paper to approach grief in their teams compassionately and effectively. Whether the grief is anticipatory, disenfranchised, or evolves into complicated grief, effective leaders can have a lasting impact on individuals facing painful losses.

 

Our approach to educating leaders about grief and loss focused on the relationship portion of Gass’ Wheel of Change. Although some policies and structures needed to be developed or modified to support and accommodate health care workers during the pandemic, a focus on building relationships and providing safe spaces for discussion was equally important. This balanced model allows leaders to guide their teams and organizations through the darkest night.

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References

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4.Kessler D, Brown B. David Kessler and Brené on grief and finding meaning. Podcast. Brené Brown; 31 Mar. 2020. Available: https://tinyurl.com/26c98636

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11.Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma 2020;12(S1):S138-40. https://doi.org/10.1037/tra0000698

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Author

Ethan Kutanzi is a combined Doctor of Medicine and Master of Business Administration student in the Faculty of Medicine and Dentistry at the University of Alberta.

 

Kathleen Fraser, MC, is the provincial program director, EMS Office of Respectful Workplaces, Alberta Health Services.

 

Debrah Wirtzfeld, MD, ACC, CCPE, ICD.D MBA, is a professor of surgery in the Faculty of Medicine and Dentistry at the University of Alberta. She is also the associate chief medical officer of Physician Health, Diversity & Wellness for Alberta Health Services. She is a certified executive leadership coach and change management consultant.

 

Author attestation: All authors contributed to the conception and design of the work, drafting, and revisions to reflect intellectual content; Dr. Wirtzfeld approved the final version to be published. All authors agree to be accountable for all aspects of the work related to accuracy and integrity.

 

Correspondence to:

debrah.wirtzfeld@albertahealthservices.ca

 

This article has been peer reviewed.

 

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