We find ourselves nearing the end of the year 2020. It has been a year like no other. We often pause at year end to reflect on what has gone well and what can be improved. The ongoing coronavirus disease 2019 (COVID-19) pandemic, while taking a toll, has taught us much about teamwork, innovation, selflessness, and the resilience of our frontline health care providers. As acute and critical care nurses, you have provided the most holistic care you have ever imagined possible, including substituting for family for many of your critically ill patients. For patients who were dying, you often provided the final personal touch and the final voice. As a nurse, you are stronger than you may have thought possible. Although many of you experienced the most challenging moments of your career, you rose to the occasion, you were “All In.”1 

It would be remiss of me to close out the year without honoring our fallen colleagues—those whose lives ended too early, who likely contracted COVID-19 while caring for others. Let us honor the health care workers who died during the pandemic and also focus on the grieving process for those of you who continue to save lives. Many of you have suffered the loss of patients, colleagues, family, friends, and other loved ones during the pandemic. At the time of writing, surges in COVID-19 patients are still occurring in the United States and other countries. Many nurses continue to function in “busy mode” and have not permitted themselves time to stop to reflect and grieve.

Sadly, at the time of writing, an estimated 7000 or more health care workers from around the world have died from COVID-19.2  Many speculate that the number is grossly underestimated because of varied pandemic reporting practices. In September 2020, the International Council of Nurses reported that more than 1000 nurses in 44 countries had died of COVID-19, and rates in health care workers represented 10% of all COVID-19 infections globally.3  Within the US, The Guardian partnered with Kaiser Health News to document every American health care worker who died of COVID-19.4  Of the 1361 US health care providers who died, more people of color and nurses (85) have died compared with other races and health care disciplines.5 

The majority of media reports speak about the number of deaths. We hear about aggregate losses in the news, but often lose sight of the individuals who lost their lives. What we have lost are people, real people who were valuable and meaningful to our critical care community. We lost a considerable amount of critical care knowledge, experience, and talent that cannot be easily replaced. We have lost trusted colleagues who had our back, who mentored us, and who shared laughs and cried with us. Not only were the deceased your colleagues, in many cases, these people were your friends, and, in some cases, they were family or loved ones. As a critical care community, we have suffered a tremendous loss. What also saddens me is that we are not through this crisis. The pandemic continues to loom over us and places additional burden and risk on our acute and critical care health care providers. My greatest hope is that you all have adequate personal protective equipment (PPE) and remain safe.

Two US websites have been created in an effort to profile health care workers who have died.5,6  The life stories and professional contributions of these health care workers are highlighted, and personal touches are included to show the human side of these bright lights that have been taken too early. Journalists continue to update multiple websites honoring health care workers who died of COVID-19; they encourage you to submit names and stories of health care workers who died to ensure that their legacy continues.7-10 

You may have already honored fallen colleagues in your own way on an individual basis or with your team. Honoring those who have died through a short observance known as The Pause is a practice that you may be familiar with. The Pause was developed by critical care nurse Jonathon Bartels for critical care nurses and their teams11 ; this practice originated in the emergency department as a way for frontline providers to formally gather at the bedside and honor the deceased. It was also a way for health care providers to take a breath and reflect on their contribution to the individual instead of rushing away to another complex and busy emergency immediately following resuscitation efforts.11  As an intensive care unit nurse, I know too well what it is like to suddenly transition delivery of care from lifesaving to withdrawal of life-sustaining treatment or to death within a split second. This rapid transition can feel emotionally and physically draining.

As a practice used by many critical care providers, The Pause seems fitting to honor our fallen colleagues. I asked Jonathon Bartels for his thoughts on this situation:

In this unprecedented time of a pandemic and social/political upheaval, it is imperative we find the time to stop. Life is moving at such a rapid pace and we are exposed to so many variables that can weigh so heavy. We have been placed in challenging positions through lack of PPE, been exposed and either caught COVID or know friends who have, watched and been present as both caregivers and patients die. The practice of The Pause is no panacea, but it is an invitation to slow down and honor in our own way. Honor our own struggles and the very real struggles and losses both of our own and those around us. (J. B. Bartels, RN, email, September 5, 2020)

According to the Institute for Healthcare Improvement,12  “Grief is a near-universal aspect of disasters.” Grief during the pandemic may be due to a variety of sources, such as loss of general safety; loss of autonomy; separation from family; financial loss; lack of patient visitation; social distancing; social isolation; and death of patients, colleagues, and loved ones.13  Complicated grief can result from the type and volume of losses experienced and may include the bereavement process itself.13  Although coping strategies such as avoidance and/or distancing may allow health care workers to continue caring for patients during the pandemic,14  they can also lead to unresolved grief if they are not properly dealt with.13  We each cope with death and dying in our own personal way,14  yet it is necessary to openly acknowledge our grief to begin dealing with pain and loss.12  Talking about your experiences, including end-of-life care, with friends, families, and/or colleagues has been found to help to validate feelings, share grief, and provide healing support.14,15  Strategies to enhance positive coping mechanisms also include self-care such as exercise, sleep, healthy diet, leisure activities, and spiritual or religious support.14  Although self-care during the midst of a pandemic may seem counterintuitive,13  it helps health care workers to cope with death and continue to provide compassionate, empathetic, and effective care.16 

Debriefing sessions are an effective coping method for grieving and dealing with death.14  However, Zheng and colleagues14  found that some nurses expressed hesitation to participate in group sessions, fearing ridicule from more senior colleagues. Other suggestions to deal with death experiences may include a formal mentoring program, such as the Battle Buddy system used by the US Army.12  Two people who experienced a similar crisis are partnered with the expectation to communicate regularly and provide encouragement for each other.12  Zheng et al14  also suggested that a mentoring program to pair nurses who have more patient death experience may be helpful to support nurses with less death experience.

Historically, nurses have been expected to manage grief on their own.14  Health care leaders can actively assist with healing and recovery by providing grief leadership. Leaders are encouraged to acknowledge and address grief, communicate openly, facilitate processes to honor losses, and assist employees to create a vision of hope for the future.12  For leaders looking for ways to support their nurses and frontline health care providers, COVID-19: Grief Leadership and System Supports resources are available on the Institute for Healthcare Improvement website.12,17 

As we prepare to transition into a new year, we must openly acknowledge the pain, suffering, grief, and death that have occurred during the past year. The year 2020 has been a year like no other. I hope you will join me as I pause to take a big breath, reflect, and honor our fallen colleagues. I will also be thinking about all of you and how much you have given of yourselves during the past year. I honor each of you. Many of you have heard the phrase “it takes a village”—frontline health care providers and their teams have been that village during the year 2020.

Please take good care and know that you are deeply appreciated. Sending my best wishes for the New Year!

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Footnotes

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