‘Nothing is certain except death and taxes’; Benjamin Franklin, 1789 (National Constitution Center, 2019). The former is particularly true for pet owners and veterinary professionals; the animals we care for mostly live lives much shorter than our own. Issues of euthanasia and end-of-life care are regularly cited as stressors in the literature on veterinary burnout, compassion fatigue and moral injury (Deacon and Brough, 2017).
Veterinary nurses often experience bereavement from multiple directions; as carers for animals that die, as part of the team responsible for euthanasia, as witnesses and supporters for clients experiencing bereavement, and frequently as pet owners themselves (Marton et al, 2020).
Often terms like grief, bereavement and mourning can be used interchangeably. In studies of loss, bereavement is generally considered to refer to the entire process of loss, grief and mourning (Zisook et al, 2014). It can also include the period leading up to a loss, such as in the case of palliative care when it is known that death will be the final outcome; this is referred to as anticipatory grief. Mourning refers to the outward behaviours related to grief, such as expressing sadness or anger. It also includes personal or cultural actions such as holding memorial services. Grief itself is the normal and natural response to loss; it may take many forms, depending on the people and animals involved.
Stages of bereavement
Early models of bereavement, such as the five stages model created by Elisabeth Kübler-Ross in 1969, described grief as a process, with the people involved passing through stages such as denial, anger, bargaining, depression and acceptance (Kübler-Ross, 1969). While many people may indeed pass through these stages, it is now widely accepted that bereavement is a very personal process (Stroebe et al, 2017). People may pass through these stages, but the order will vary, as will the duration, and some people may not pass through all stages. A more modern approach is to think of two main stages – acute grief and integrated grief (Bui, 2018). Acute grief is the immediate stage following a loss, where dysphoric emotions such as sadness, anger or disbelief can affect the individual, sometimes reducing their ability to function normally. There can also be positive emotions; reminiscences on happy memories of the deceased can bring comfort. There is no commonly agreed time frame for acute grief, but many people will move towards integrated grief over a period of months. Integrated grief is the long-term process of accepting loss. This does not mean an end to grief, but a movement to acceptance and normal function in life, and the ability to perceive possibilities for future happiness.
While this may describe the process of grief for most people, grief and bereavement are unique to each individual and loss. Some losses are harder to deal with than others, and the circumstances that surround the loss can have an effect as well. These issues are often described as ‘complicated grief ’ (Shear, 2015). A range of different factors can contribute to this experience, such as multiple losses over a short period of time, loss of an animal that was relied on for emotional support, or the effects of psychological conditions such as major depressive disorder or post-traumatic stress disorder. These unique combinations of issues can make it hard for someone to accept a loss or difficult to reduce the negative effects of grief on their life. Another related issue is prolonged grief disorder. Sometimes the acute feelings of grief and loss can last much longer than is common, and again this is affected by the unique circumstances of the individual.
Anticipatory and disenfranchised grief
Two more key issues affecting the experience of bereavement for veterinary nurses are anticipatory grief and disenfranchised grief. Anticipatory grief is a common experience for those working in the veterinary profession; it describes the feelings of grief and loss that can occur before the loss itself (Laing and Maylea, 2018). Veterinary nurses are well aware of the shorter lifespans of many companion animals and the factors that can lead to death from trauma, disease or euthanasia. It is natural to realise that a beloved pet or favourite patient will one day be gone, and to be upset by this thought. Anticipatory grief can become acute as animals age and/or are diagnosed with lifelimiting conditions and this can affect end-of-life decision making. Disenfranchised grief is having one's grief dismissed as being inappropriate or unsuitable (Marton et al, 2020). The classic example would be the comment, ‘Why are you so upset? It was just a dog’. People who do not have strong connections with animals can sometimes find it hard to understand that the experience of losing an animal can be just as affecting and debilitating as losing a human. Attitudes such as these can cause owners to feel that their grief is somehow inappropriate, that they are not permitted to feel or express their feelings. This increases the sense of isolation that grief can produce and reduces the willingness to share feelings or ask for help. In reality, feelings of grief are the result of the individual's relationship with the person or animal that has died. Comparison to the loss of a human, such as those implied by the comment above are also unhelpful because each experience of bereavement is unique. It is not possible to compare the loss of a parent, child or pet and say that one is always worse than the others; it is always dependent on the specific circumstances for the person experiencing bereavement.
Bereavement and veterinary nurses
Having introduced the key elements of grief and bereavement, how do these factors apply to veterinary nurses specifically? Starting from the beginning, veterinary nurses will experience bereavement and grief just like anybody else. While veterinary nurses maintain a degree of professional detachment, that does not mean they are unemotional. Veterinary nurses lose their own pets and may develop strong bonds with their patients. Experiencing normal grief and bereavement are to be expected. The unique role of veterinary nurses also creates risk factors for other types of grief. Complicated grief can easily occur when veterinary nurses are exposed to multiple euthanasias, deaths after perceived futile care or convenience euthanasia, having to conduct euthanasia after losing one's own pet, and many other experiences. Prolonged grief is also a risk; when a veterinary nurse may be exposed to grief and loss on a daily or weekly basis, it is not surprising that this could make it more difficult for them to process their own grief. The risk factors for anticipatory grief are discussed above, and are likely to affect many veterinary nurses. Even in a profession where everyone has chosen to care for animals, grief among professionals can still be dismissed as unprofessional or a sign of weakness. This can lead veterinary nurses to question whether they are suited to the profession (Paul et al, 2023).
It is not possible to prevent bereavement or grief. However, there are some good methods for supporting people who are experiencing them. Many clinics now provide strong support for clients. Euthanasia may be scheduled later in the day, so people have time to sit and say goodbye. Memorials such as pet footprints are offered. Owners are also directed towards resources such as the Blue Cross pet loss helpline. Similar considerations can help veterinary nurses deal with loss as well. The simple act of acknowledging grief and allowing people to express it can be very healing (McKinney, 2019). Knowing that the professional community and team understand what you are going through and accept it as normal reduces stigma and helps with the processing of emotions. Having a space to retreat to when feelings become overwhelming, a safe space within the practice, can help support those who are generally fine to work but might need a few minutes away to allow themselves to react. Understanding also helps to allow people to react in their own way; some might be numb and seem uncaring, some may cry, some may be angry. Accepting that these are all natural responses, with no right or wrong way to grieve, can also help people to feel supported.
Memorialisation
As for any pet owners, memorialisation can help. For veterinary nurses losing their own pets, having options such as paw prints or ashes transformed into jewellery can provide a focus point for reliving positive memories (Kogan et al, 2022). For many people, memorials are a way to keep the memory of that animal alive. This is more difficult when it comes to the grief a veterinary nurse may feel at the passing of a favourite patient, as disposal and memorials are not at their discretion. However, it is possible that clients would be open to the idea of a veterinary nurse taking paw prints or other non-intrusive memorial options. This could even improve the experience of the client; knowing that your pet was well loved by the veterinary staff and will be missed helps to validate their own grief and show that it is shared by others. For the client and the veterinary team, this feeling of communal bereavement can also give a sense of support. Any such suggestions would have to be made carefully and sensitively, and might not be appropriate in all circumstances.
Getting support
An understanding of grief can also help veterinary nurses who may be experiencing complicated or prolonged grief (Boelen and Smid, 2017). Knowing when to look for support from counsellors or other mental health professionals can allow affected veterinary nurses to pursue help earlier and make any required adjustments at work (in agreement with managers). Tackling these issues as soon as they are recognised can reduce time lost as a result and help veterinary nurses make an earlier transition back to a full workload, to the benefit of themselves and the practice. There should be procedures in all practices to support staff with mental health issues; in these cases, it requires recognition that individuals experiencing complicated or prolonged grief may require support and intervention within these processes.
The positive side of grief
While it can be hard to see the positive side of bereavement, there is a phenomenon known as post-traumatic growth (Michael and Cooper, 2013). This experience goes beyond simply coping with the process of grief; those experiencing post-traumatic growth may describe it as a transformational experience which affects their outlook on life or future behaviour. For example, someone might realise that they had taken their relationship with their pet somewhat for granted and elect to spend more time in the future enjoying the time spent with animal companions. Another example could be a person better understanding the effect of bereavement on others, and becoming more compassionate to those who are in the throes of grief. In some ways this is the opposite of post-traumatic stress disorder, although it is not the trauma itself that causes personal change, but the experience of coping with trauma.
Conclusions
In summary, veterinary nurses and other animal professionals can experience bereavement and resultant grief. This can occur from any animal they have a connection with, not just personal pets. Grief is normal and natural and should not be stigmatised in any way. Showing compassion and support for colleagues is one way to reduce stigma and the risk of complicated or disenfranchised grief. Knowing and understanding the bereavement process helps to support both clients and colleagues to work through the process of grief in their own time and way. Finally, being aware of the risks of prolonged grief or complicated grief can help with providing mental health support where needed.
KEY POINTS
- Grief is normal and natural.
- Veterinary nurses may feel grief from loss of any loved animal, not only personal pets.
- People need space and the opportunity to work through the grief process.
- Understanding bereavement and grief helps veterinary nurses support both clients and colleagues.