Articulating Grief: Arts‐Based Therapy as a Pathway to Resilience in Nursing Practice

ABSTRACT

Grief and bereavement are profound yet underexplored aspects of nursing practice within residential aged care facilities. Registered nurses who work in these settings often form close emotional bonds with residents, making repeated exposure to death deeply impactful. This study aimed to depict the grief, loss, and bereavement experiences of registered nurses in aged care through an arts‐based qualitative approach. Nine nurses participated in a one‐hour creative session involving drawing or painting to express their experiences of grief and loss. The artworks and accompanying narratives were analysed using a combined deductive and inductive approach guided by Guillemin's adaptation of Rose's critical visual methodology framework. Three key themes emerged: (i) symbolic use of colour, where colours conveyed emotions such as grief, peace, and transformation; (ii) elements of transformation, with imagery evolving from depictions of death and turmoil to representations of acceptance and renewal; and (iii) meaningful motifs, where symbols such as butterflies, birds, and domes represented peace, connection, and spirituality. Collectively, the artworks illustrated how grief, while painful, can evolve into acceptance and peace through creative expression. This study demonstrates the capacity of arts‐based methods to reveal the emotional complexity of grief among aged care nurses, highlighting symbolism and colour as powerful tools for emotional understanding. Integrating creative approaches into professional development and emotional support initiatives may enhance wellbeing, reduce burnout, and improve retention. Further research should explore the long‐term emotional effects of grief and the therapeutic potential of structured creative interventions in nursing practice.

1. Introduction

Grief and loss are pervasive yet underexplored dimensions of nursing practice, particularly within residential aged care facilities (RACFs). These settings, which often serve as the final residence for older adults, expose registered nurses (RNs) to recurrent experiences of death and dying (Puyat et al. 2019). Unlike acute care environments, RACFs foster sustained interpersonal relationships between nurses and residents, resulting in emotional attachments that amplify the psychological impact of resident deaths (Stubbs et al. 2025; Hilberdink et al. 2023). The depth of these bonds frequently renders nurses' grief analogous to familial bereavement, a phenomenon that remains insufficiently acknowledged within clinical discourse and organisational frameworks (Oates and Maani‐Fogelman 2024; Granek 2014).

Despite the profound emotional toll, grief among aged care nurses is frequently internalised and unsupported, contributing to psychological distress, professional burnout, and diminished quality of care (Sharif et al. 2025; Puyat et al. 2019). The absence of structured grief support mechanisms within RACFs exacerbates this issue, compelling nurses to rely on personal coping strategies that may be inadequate or maladaptive (Thompson and Cox 2017). This lack of institutional recognition is particularly concerning in light of global demographic shifts, including the increasing proportion (Nations 2024) of older people and the escalating demand for aged care services, which place increasing emotional and operational pressures on nursing staff (Studies 2024).

In response to these challenges, arts‐based research methodologies offer a compelling and empathetic framework for exploring grief in nursing (Chesham 2024). This component of the study complements findings from a parallel interview‐based inquiry, where participants' verbal reflections on grief were enriched through visual expression (2). By facilitating creative expression such as drawing, painting, or narrative art, these approaches enable nurses to externalise and process complex emotional experiences that may be difficult to articulate through conventional verbal methods. This paradigm aligns with contemporary calls for holistic and reflective models of nursing research that prioritise emotional wellbeing, professional sustainability, and the cultivation of resilience (Leavy 2020). Through arts‐based inquiry, researchers can generate complex insights into the lived experiences of grief among aged care nurses, thereby informing the development of supportive interventions and fostering a more compassionate organisational culture.

1.1. Background

Bereavement, defined as the state of having lost a significant individual, typically evokes a period of intense sorrow and emotional disruption (Hilberdink et al. 2023). Grief, the emotional response to bereavement, is a universal human experience characterised by sadness, longing, and psychological disorientation (Granek 2014). Within the context of nursing, grief extends beyond personal loss to encompass professional relationships, particularly in RACFs where nurses often engage in long‐term, emotionally invested care (Ådland et al. 2022; Alodhialah et al. 2024).

RNs in aged care settings occupy a unique position within the healthcare continuum. Their responsibilities transcend clinical duties to include emotional support, companionship, and advocacy for residents approaching the end of life (Ratcliffe et al. 2023). This multifaceted role fosters deep attachments that, when severed by death, elicit profound emotional responses. The phenomenon of cumulative grief, a form of emotional fatigue resulting from repeated exposure to loss, is particularly salient among aged care nurses and has been shown to contribute to burnout and psychological distress (Mercer and Evans 2006; Feng et al. 2024).

Empirical evidence underscores the vulnerability of RNs in RACFs to grief‐related complications. A cross‐sectional study involving 553 nurses across 37 facilities revealed significantly elevated levels of emotional exhaustion and depersonalisation among those experiencing grief, compared to other staff members (Hawes and Wang 2024). Despite these findings, grief is often construed as a personal vulnerability rather than a legitimate occupational concern, leading to its marginalisation in organisational policy and practice (Shi et al. 2022). The emotional labour inherent in end‐of‐life care is further compounded by systemic challenges such as understaffing, time constraints, and the absence of formal support structures. In such environments, nurses may internalise grief as a professional inadequacy, thereby inhibiting help‐seeking behaviours and perpetuating emotional distress (Crape et al. 2025).

Organisational cultures that valorise stoicism and emotional detachment exacerbate this issue, rendering the emotional realities of caregiving invisible and unaddressed (Sharif et al. 2025). In response, scholars have advocated for culturally sensitive and context‐specific approaches to grief support that reflect the diverse socio‐cultural backgrounds of nursing staff. For instance, Sharif et al. (2025) emphasise the importance of tailored coping strategies, while Oates and Maani‐Fogelman (2024) call for institutional policies that recognise and accommodate the emotional dimensions of caregiving.

Arts‐based methodologies offer a promising avenue for addressing these challenges. By enabling nurses to engage in creative expression, such approaches facilitate emotional processing, foster psychological resilience, and provide a non‐verbal medium through which grief can be explored and validated. This study builds upon emerging evidence by applying arts‐based methods to investigate the lived experiences of grief and loss among RNs in RACFs, thereby contributing to the development of empathetic, sustainable, and contextually relevant models of aged care practice.

2. Methods

2.1. Design

A qualitative arts‐based study was conducted to explore the lived experiences of grief and loss among RNs working in RACFs. Arts‐based research, situated within interpretivist paradigms, enables the exploration of emotional and existential dimensions of human experience through creative modalities (Guillemin 2004). The design aligns with contemporary qualitative traditions that prioritise depth, meaning‐making, and participant voice in understanding complex phenomena such as bereavement in caregiving contexts. Detailed methods are outlined in Appendices A, B, and C including drawing/painting materials (Appendix A), data collection methods (Appendix B), and an overview of arts‐based research (Appendix C).

2.2. Theoretical Framework

The study was guided by Guillemin's (2004) adaptation of Rose's (2016) critical visual methodology framework, which provides a structured lens for interpreting visual data. This framework examines three core dimensions: the process of image production, the compositional elements of the image, and the relational dynamics between the image and its audience (Rose 2016; Guillemin 2004). It is particularly suited to arts‐based inquiry, as it facilitates the integration of visual and narrative data while acknowledging the socio‐cultural and emotional contexts in which images are created. The framework complements nursing theories of emotional labour (Hochschild 2012) and person‐centred care (McCormack et al. 2017), which recognise the relational and affective dimensions of nursing practice.

2.3. Aim

To investigate the emotional and professional impact of grief and loss experienced by RNs in RACFs, and to evaluate the potential of arts‐based methodologies as a means of emotional expression and support.

2.4. Objective

To apply arts‐based research methods to explore how RNs in RACFs experience, internalise, and express grief following resident deaths.

2.5. Research Question

How do RNs in RACFs experience and express grief following the death of long‐term residents, and in what ways can arts‐based methodologies facilitate emotional processing and professional resilience?

2.6. Study Setting and Recruitment

The study was conducted across multiple RACFs in New South Wales, Australia, between February and August 2024. This setting was selected due to the frequent exposure RNs have to death and dying in their daily practice, which may have implications for understanding the broader experiences and responses of RNs across healthcare settings. Participants were recruited consecutively through facility networks using purposive sampling to ensure relevance to the research question (Stratton 2024). Recruitment materials were distributed via internal communications and professional networks. All participants were provided with detailed information about the study and invited to participate voluntarily. Written informed consent was obtained from all participants prior to study commencement. As part of the consent process, participants were informed that any information used in publications would be unidentifiable.

2.7. Sample Size

In qualitative studies, data saturation is used instead of formal sample size calculations. Saturation is achieved when adding more participants to the study does not yield new perspectives or information (Sutton and Austin 2015). In considering the nature of the study and data saturation, the number of participants tallied n = 9. Currently, no arts‐based studies explore RNs' experience of grief, loss and bereavement in RACFs to inform sample size. There was 0% nonparticipation and withdrawal rates in this study, as completion of the single arts‐based activity was voluntary.

2.8. Inclusion and/or Exclusion Criteria

Eligibility criteria were designed to ensure that participants had direct experience with resident death and were currently engaged in aged care nursing practice. Criteria are outlined in Table 1.

TABLE 1.

Eligibility criteria.

Inclusion criteria	Exclusion criteria
1. Aged > 18 years of age or older	1. Aged < 18 years or younger
2. English speaking	2. Non‐English speaking
3. Current AHPRA Division 1 RN	3. Not current AHPRA Division 1 RN
4. Currently working in a RACF	4. Not currently working in a RACF
5. Experience with resident death	5. No experience with resident death
6. Willing to provide consent	6. Not willing to provide consent

Abbreviations: AHPRA, Australian Health Practitioner Regulation Agency; RACF, Residential Aged Care Facility; RN, Registered Nurse.

2.9. Data Collection

All participants completed a 1‐h face‐to‐face, one‐on‐one arts‐based activity. To ensure uniformity, the same researcher (MAS), an experienced female RN, nurse academic, and qualitative researcher, facilitated all arts‐based activities. Additionally, MAS had no prior relationship with participants. Sociodemographic data, specifically gender identity, age, living arrangement, country of birth, education level, years in occupation, employment status, and grief reactions were collected prior to completion of the arts‐based activity (Table 2).

TABLE 2.

Sociodemographic results.

Characteristic	Value
Total sample, n	9
Gender identity—female, n (%)	5 (56.0)
Age (years), mean ± SD
Female	35.8 ± 11.2
Male	27.2 ± 3.2
Total	32.0 ± 9.3
Living arrangement, n (%)
Married	3 (33.3)
Never married	4 (44.4)
Separated	1 (11.1)
Divorced	1 (11.1)
Country of birth, n (%)
Australia	3 (33.3)
Kenya	1 (11.1)
Myanmar	1 (11.1)
Nepal	2 (22.2)
Pakistan	1 (11.1)
Philippines	1 (11.1)
Education level, n (%)
Bachelor	9 (100.0)
Graduate Certificate	1 (11.1)
Specialised education, n (%)
Leadership and management	2 (22.2)
Dementia care	1 (11.1)
Palliative care	1 (11.1)
Wound care	1 (11.1)
Ear syringe	1 (11.1)
Certificate IV Training and Assessing	1 (11.1)
Working in RACFs (years), mean ± SD	4.8 ± 2.3
Employment status—fulltime, n (%)	7 (77.8)
Grief reactions, n (%)
Physical reactions
None	7 (77.8)
Fatigue or exhaustion	3 (33.3)
Exhaustion	2 (22.2)
Rapid heartbeat	2 (22.2)
Lump in throat	2 (22.2)
Hollow feeling in stomach	1 (11.1)
Deep sighing	1 (11.1)
Sleep disturbance	2 (22.2)
Decreased appetite	1 (11.1)
Cognitive reactions
None	3 (33.3)
Increased dreams	3 (33.3)
Preoccupation with death	2 (22.2)
Disbelief	2 (22.2)
Difficulty concentrating	3 (33.3)
Emotional reactions
None	2 (22.2)
Sadness	7 (77.8)
Helplessness	1 (11.1)
Numbness	2 (22.2)
Relief	1 (11.1)
Calm	4 (44.4)
Mood swings	1 (11.1)
Anxious	1 (11.1)
Behavioural reactions
None	7 (77.8)
Avoidance of people	1 (11.1)
Increased alcohol use	1 (11.1)
Spiritual reactions
None	7 (77.8)
Loss of faith	1 (11.1)
Strengthening of faith	1 (11.1)

Note: Descriptive data presented as number (n) and percent (%) or mean ± SD (standard deviation).

To complete the art activity, all participants were provided with various drawing and painting materials (Appendix A). The researcher (MAS) gave verbal instructions using a standardised script (Appendix B). Participants were asked to illustrate their experience of grief and loss through drawing or painting, with an emphasis on personal experiences rather than artistic ability.

Once artworks were completed (confirmed verbally by the researcher), participants described their creations to facilitate interpretation and analysis. The discussion was guided by Guillemin's adaptation of Rose's critical visual methodology framework (Guillemin 2004; Rose 2016). This framework examines the process of image production, the composition of the image, and the relationship between the image and its audience. It also informed the development of prompting questions (Appendix A). Participant's descriptions of their artwork were voice‐recorded and transcribed verbatim.

2.10. Data Analysis

In this study, reliability and validity were ensured through triangulation including artwork creation, artwork narratives, researcher observations, and the use of Guillemin's adaptation of Rose's critical visual methodology framework (Rose 2016; Guillemin 2004).

2.10.1. Quantitative Analysis

Analysis of quantitative data was performed using STATA v.15 software. Descriptive statistics were used to characterise the population. Reporting of variables was decided based on the normality of the data spread. Parametric variables are reported as means (standard deviation (SD)).

2.10.2. Qualitative Analysis

Qualitative data analysis involved a deductive/inductive and content/thematic approach (Braun and Clarke 2006). Artwork descriptive data transcripts were coded using NVivo software. The lead researcher (MAS) coded transcript data according to categories, achieving 95% agreement with a Kappa coefficient of over 0.75 when compared with a second researcher (JR). Patterns and frequencies within categories were then explored to generate themes. Conflicting data interpretation was resolved through discussions with co‐authors JR, MG, CS, and MAS. Transcripts were regularly reviewed, with artwork descriptive data compared for consistency using coding stripes.

2.11. Ethical Considerations

Ethical approval was obtained from the University of Newcastle (H‐2022‐0348). The study was conducted in accordance with the Declaration of Helsinki and conforms to Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al. 2007).

2.12. Rigour and Reflexivity

To ensure methodological rigour and uphold reflexivity throughout this arts‐based study, a multi‐step approach was employed. The research design was grounded in established arts‐based inquiry frameworks, with clear articulation of epistemological and ontological assumptions (Rose 2016, Guillemin 2004). Data collection and creative processes were documented in detail (Appendix A), including iterative cycles of creation, reflection, and revision. Reflexive journaling was maintained by the lead researcher (MAS) to judiciously examine positionality, assumptions, and emotional responses during both the arts‐based activity and subsequent data analysis (Faulkner et al. 2016).

Member checking was completed with all participants. In the context of arts‐based research, this process was not used to validate a singular interpretation, but rather as a reflexive, participatory analytic strategy that aligns with the ethos of co‐construction and multiplicity of meaning (Rose 2016; Satchwell et al. 2020). Participants engaged with their own creative output, deepening understanding of the social and cultural contexts embedded in their work. This approach supported collaborative interpretation without reducing the artwork to a single, fixed meaning, thereby maintaining both artistic integrity and research rigour.

3. Findings

3.1. Participant Characteristics

Sociodemographic results are detailed in Table 2. The study included a total sample of n = 9 participants, with a majority identifying as female (n = 5, 56%). The mean age of participants was 32.0 years (SD ± 9.3), with females averaging 35.8 years (SD ± 11.2) and males averaging 27.2 years (SD ± 3.2). Participants were mostly unmarried, with 44.4% never having married. The cohort was diverse in terms of country of birth, with 3 (33.3%) from Australia, and the remainder from countries including Kenya, Myanmar, Nepal, Pakistan, and the Philippines. All participants had a bachelor's degree in nursing. A range of specialised further education was reported, including leadership and management (n = 2, 22.2%), dementia care (n = 1, 11.1%), and palliative care (n = 1, 11.1%). The average experience working in RACFs was 4.8 years (SD ± 2.3), with most employed full‐time (n = 7, 77.8%).

Grief reactions varied among participants. No reactions to grief (physical, behavioural or spiritual) (77.8%) were common in participants. Cognitive reactions of preoccupation with death and difficulty concentrating (33.3%), emotional responses of sadness (77.8%) and mood swings (44.4%) were reported (Table 2).

3.2. Colour Representation in Artworks

Participants expressed symbolistic use of colour within artworks. Colour was logically used to denote peace, comfort and happiness. A male participant voiced ‘dull colours signify grief and sadness, while colourful elements represent a happier, better place’ (participant RN06, 34 years) (Figure 1A). A 30‐year‐old female participant expressed ‘dark colours represent sadness, while bright colours like green and orange represent happiness’ (participant RN01). Conversely, participants transpose the use of colour symbolism. A male 25‐year‐old participant commented ‘there is no particular colour representation’ (participant RN05) (Figure 1B). Further, a 34‐year‐old female participant voiced ‘colours do not represent anything specific; they were chosen for their simplicity’ (participant RN08) (Figure 1C).

FIGURE 1.

(A–C) Symbolic use of colour in artworks depicting grief and loss. Participant artworks illustrate diverse emotional interpretations of colour. (A) Dull tones represent grief and sadness, while bright colours convey peace and happiness (RN06, male, 34 years). (B) Absence of symbolic colour use, reflecting neutrality in emotional expression (RN05, male, 25 years). (C) Simplistic use of colour without specific emotional representation (RN08, female, 34 years).

3.3. First Element Created in Artworks

Artwork descriptions revealed elements of death, grief, and transformation being first drawn/painted in artworks. A 34‐year‐old female participant voiced ‘I started with the background showing death and dying, setting a sombre tone’ (participant RN08) (Figure 1C). Similarly, a 30‐year‐old male participant articulating they ‘started with an outline of a head to represent brain activity, illustrating the internal struggles and emotions associated with loss’ (participant RN03) (Figure 2A). Family grief and difficulty accepting death was expressed by a female participant aged 55 years. This participant voiced the turmoil of dealing with impending death expressing ‘the confusion and pain experienced by both the dying and their loved ones needed to come first’ (participant RN09) (Figure 2B). Opposing sombre and sad first created elements is the process of death illustrated and expressed by a 24‐year‐old male participant as ‘peaceful and natural’, describing ‘first element was the symbolic transformation and the belief that death brings an end to suffering’ (participant RN04) (Figure 2C).

FIGURE 2.

(A–C) Initial elements depicting grief, death, and transformation. Artworks reveal how participants began by illustrating key emotional and symbolic elements of loss. (A) Depiction of a head outline representing internal struggle and mental processing of grief (RN03, male, 30 years). (B) Imagery reflecting family grief and the emotional turmoil of impending death (RN09, female, 55 years). (C) Peaceful portrayal of death as a natural and transformative process ending suffering (RN04, male, 24 years).

3.4. Meaningful Elements in Artworks

Spiritual elements were common in artworks. A 25‐year‐old male participant depicted a dome representing a connection with faith during times of grief and serving as a refuge for comfort (participant RN05) (Figure 1B). A bright yellow sun detailed in artworks suggested peace in death and illustrated how death was considered a positive transition, not always a bad thing (Figure 1A). Serenity in death was expressed by participants RN06 and RN07 as ‘warm, bright, and representing peace, happiness and better days’ and ‘reflecting the peace that some people find in death’ respectively (Figures 1A and 3A). The spiritual concept of freedom was depicted via purposeful inclusion of butterflies and birds (Figure 3A) and described as ‘the birds are that flight of freedom, being met by a loved one on their journey, or just them as their flight of freedom. They've gained their wings to me, is what happens’ (participant RN09) (Figure 2B).

FIGURE 3.

(A and B) Spiritual and environmental elements symbolising peace and connection. Artworks illustrate spirituality and comfort in death. (A) Use of bright colours, birds, and butterflies to symbolise freedom, peace, and spiritual transformation (RN07, female, 34 years). (B) Representation of death occurring in a familiar environment, reflecting comfort, dignity, and acceptance at the end of life (RN02, female, 26 years).

The importance of residents dying in their own environment reflected a desire for comfort and familiarity at the end of life. A 26‐year‐old female participant expressed ‘this is a real‐life representation of what happens when someone dies’ (participant RN02) (Figure 3B). Overall, meaningful elements of artworks portrayed how grief, while deeply painful, may be transformed into peace, acceptance, and spiritual connection.

4. Discussion

4.1. Main Findings/Results of the Study

This study aimed to gain a rich understanding of how RNs in RACFs experience and express grief following the death of long‐term residents, and in what ways can arts‐based methodologies facilitate emotional processing and professional resilience. This component of the study complements findings from a parallel interview‐based inquiry (2), indicating that while verbal reflection represents one mode of coping with grief, artistic expression offers a distinct yet complementary means of understanding and processing loss. This study is novel as it is the first to use arts‐based methodology (drawing and painting) to illustrate and explore individual grief and bereavement experiences of RNs working in RACFs. Artworks served as a non‐verbal facilitator, enabling participants to communicate the meanings of their experiences. As artworks are subjective, accompanying verbal descriptions provided further insight into participants' experiences. Diversity of experience was highlighted via the use of tropes (metaphors and metonymy) and expressionism. The use of similar techniques is reported in a study exploring the experience of people living with severe asthma, anxiety and depression (Stubbs et al. 2021).

Artworks of participants show vivid descriptions and application of colour. Participants described colours representing specific emotions, with dark colours representing death and bright colours representing happiness. This may be explained by the colour‐in‐context theory (Elliot and Maier 2012) and the conceptual metaphor theory of colour (Meier and Robinson 2005). Colour‐in‐context theory combines elements of social learning and biology. It suggests some reactions to colour stimuli arise primarily from repeated association of specific colours with certain concepts, messages, and experiences (Elliot and Maier 2012). The conceptual metaphor theory of colour suggests people think and talk about abstract ideas using examples from what they see and experience (i.e., they use metaphors) to help them understand (Meier and Robinson 2005). For example, death infers the absence of life or light (darkness), resulting in sadness; thus, grief is metaphorically described as ‘black sorrow’. Opposing metaphors include positive emotions and experiences that are commonly depicted and expressed in terms of lightness (rather than darkness). Even though the association of the colour black to death is centuries old (Pastoureau 2009), this study provides evidence of its currency and popularity in artworks portraying the experience of RNs working in RACFs regarding grief and loss.

The first element drawn/painted by participants was negative emotional or physical states, including darkness, pain, and suffering. This may be due to cultural narratives and societal attitudes towards death that often emphasise tragic and harrowing aspects (Sallnow et al. 2022). A qualitative study examining inferences of colour reports dark representations of death. In this study, the colour black was described by a participant as ‘an evil sinister kinda colour’ (Clarke and Costall 2008). Negative emotional states illustrated in artworks may also stem from the processing of complex emotions that occurs during art creation (Leavy 2020). Such processing allows people to recreate their unique experiences, often resulting in darker representations (Parikh 2011). Darker representations of the experience of grief and loss extend beyond artworks, with 77.8% of participants in this study reporting sadness as an emotional reaction to grief. This suggests that while emotional responses to a resident's death may lessen over time as registered nurses develop resilience and coping strategies (Stubbs et al. 2021, 2025), regular debriefing may remain valuable to ensure that registered nurses are given the opportunity to reflect on their experience of grief and loss.

Spiritual elements are portrayed in artworks and described via concepts of faith, peace, and the transition from life to death. The illustration of birds and butterflies reveals the deeply personal experience of grief and loss that transcends verbal communication of RNs working in RACFs. Spiritual symbols including domes, suns, birds, and butterflies offer comfort and suggest the possibility of freedom, transformation, and serenity in the afterlife (Womack 2005). This may be explained by the psychological construct of emotional contagion.

Emotional contagion is the transfer of emotions or moods from one person to another (an isomorphic emotional reaction) (Barsade et al. 2018). Researchers note emotional contagion can take place in and be triggered by groups of two or more individuals (Hatfield et al. 2014). Given that emotional contagion may have a collective structure and the amount of contagion is high in multi‐person environments, it may be inevitable and problematic for a negative emotion to spread like a virus throughout RACFs (Aksu et al. 2023). This highlights the importance of collective emotions and warns that older people living in RACFs (dependent on care provided by RNs) are more vulnerable to emotional contagion. As emotional contagion is a primary prerequisite of empathy (the ability to understand and share the feelings of another), the provision of education/training regarding emotional intelligence and empathy or cognitive‐behavioural programs may mitigate the spread of negative emotions among RNs and RACF residents alike (Wilkinson et al. 2017).

Emotional contagion in this study was expressed both through the creative artefacts and within the emotional climate of residential aged care. In participants' artworks, a shared expressive vocabulary of dark tones, fragmented forms, and shifting light where sombre hues signified grief and brighter elements invoked hope or peace. These served as a visual conduit for collective affect, effectively mirroring how moods flow between individuals (Herrando and Constantinides 2021; Hatfield et al. 2014). Emotional contagion more broadly has been theorised as an automatic process by which people mimic, synchronise, and thereby internalise others' emotions (e.g., facial expressions, posture, vocal cues) (Herrando and Constantinides 2021). Within the context of nursing and grief, the repeated exposure to death, relational closeness with residents, and ongoing emotional labour create fertile ground for such contagion: sadness, empathy, and distress can spread across staff and even to residents, shaping a shared emotional climate (Kohrt et al. 2020). Empirical work in nursing highlights this dynamic: emotional contagion is linked to emotional exhaustion and lowered professional commitment (Omdahl and O'Donnell 1999), and in spiritual care settings, excessive contagion is associated with depersonalisation and burnout (Zhu et al. 2022). Meanwhile, emotional contagion also underlies empathy. It serves as a substrate for affective attunement, but when unmoderated, it risks fuelling compassion fatigue and cumulative grief burden (Shen et al. 2024). Recognising emotional contagion as both a mechanism for empathic connection and a vector for shared distress emphasises the importance of integrating structured reflection, emotional regulation training, and supportive debriefing into nursing practice, especially in grief‐intensive care environments.

Furthermore, the importance of empathy should not be ignored (Moudatsou et al. 2020). In this study, empathy was illustrated in the artworks through the nurses' compassionate depictions of residents' end‐of‐life experiences, often illustrating peaceful transitions and freedom from suffering. Symbolic imagery such as butterflies, birds, and radiant light reflected the nurses' deep emotional atonement and desire for residents to find comfort and serenity in death. These visual expressions demonstrated an empathic connection that extended beyond clinical care, revealing how nurses internalised and shared in the emotional journeys of those they cared for. With the known negative relationship between burnout and empathy (high burnout—low empathy) (Wilkinson et al. 2017), the inclusion of emotional intelligence and empathy or cognitive‐behavioural programs may ease high levels of absenteeism and poor retention rates of RNs working in RACFs (Low et al. 2022). Given the global population is ageing and there is an increased demand for residential aged care workers, it is essential the experience of grief and loss in RNs working in RACFs be understood and addressed.

4.2. What This Study Adds

This study breaks new ground in nursing research by introducing arts‐based methods as a powerful tool for exploring the emotional realities of grief among registered nurses in aged care. By translating grief into visual expression, it captures the depth, nuance, and spirituality of bereavement in ways that traditional interviews cannot. The findings reveal how symbolism, colour, and creative process offer nurses a non‐verbal outlet for emotional processing, fostering resilience and reflection. In doing so, the study not only enriches qualitative research methodologies but also provides a compelling case for integrating arts‐based approaches into professional development, emotional support, and policy frameworks in aged care. It redefines how we understand and support the emotional wellbeing of nurses working at the frontline of end‐of‐life care.

RACFs present a unique landscape for RNs, where the frequency of resident deaths can deeply impact staff wellbeing. In many RACFs, the nursing workforce is composed largely of new graduate RNs (Alshammari et al. 2023) who, while clinically prepared, often face the confronting realities of end‐of‐life care early in their careers. Fortunately, many of these graduates enter the workforce with foundational training in reflective practice—a pedagogical approach that encourages self‐awareness, emotional processing, and meaning‐making (Kim and Chang 2022). When supported and embedded into the culture of care, reflective practice becomes a vital resilience‐building strategy. It enables nurses to navigate grief, moral distress, and the existential weight of their work with greater psychological safety. In this setting, arts‐based therapy can serve as a complementary tool, offering creative avenues for debriefing and emotional expression. Together, these approaches foster a more compassionate and sustainable workforce, where nurses are equipped not only to care for others but also to care for themselves.

4.3. Strengths/Weaknesses/Limitations of the Study

A key strength of this study lies in its innovative use of arts‐based methodology to explore grief and loss among RNs working in RACFs. By employing visual expression alongside narrative description, the study captured complex emotional experiences that are often difficult to articulate through conventional qualitative methods. The integration of Guillemin's adaptation of Rose's critical visual methodology provided a structured and reflexive framework for interpreting artworks, enhancing analytical rigour.

However, limitations must be acknowledged. The small sample size (n = 9) and purposive sampling strategy may limit generalisability beyond the study context. Additionally, the subjective nature of artistic interpretation introduces potential variability in analysis, despite efforts to triangulate data and maintain coding reliability. Cultural and linguistic diversity among participants, while enriching the data, may also have influenced the way grief was expressed and understood, warranting caution in cross‐cultural extrapolation. This being said, there is an increasing number of aged care workers from diverse cultural backgrounds working in RACFs.

4.4. Recommendations

This study offers important insights into how nurses experience grief and loss. However, the cross‐sectional design limits understanding of how these experiences change over time. Future studies should use the same arts‐based methods in longitudinal studies that follow nurses from undergraduate education into graduate practice. This would show how grief understanding, emotional regulation, and resilience develop with professional experience.

The focus on aged care limits the scope of findings. Studies in palliative, acute, and community settings could highlight how grief and coping differ across contexts. Future research should also explore how factors such as gender, culture, career stage, and role influence grief responses. Using inclusive and culturally safe methods will help design targeted interventions that strengthen emotional wellbeing, empathy, and retention across the nursing workforce.

Finally, combining arts‐based approaches such as reflective art journaling or creative workshops with validated measures of burnout, empathy, and resilience would add both depth and rigour. These methods may also offer a therapeutic avenue to enhance reflection, personal growth, and resilience among nurses.

4.5. Implications for Policy and Practice

This study highlights the need for aged care organisations to recognise grief as a legitimate occupational concern and to implement structured support mechanisms for RNs. The findings further advocate for the integration of arts‐based approaches into professional development programs, offering RNs a non‐verbal outlet for emotional expression and reflection.

Policy initiatives should prioritise emotional intelligence and empathy training, particularly in settings where RNs are repeatedly exposed to death and dying. Regular debriefing sessions, culturally sensitive grief support, and access to creative therapeutic resources may enhance nurse wellbeing, reduce burnout, and improve retention. By embedding these practices into organisational culture, RACFs may foster emotionally resilient clinicians and deliver more compassionate, person‐centred care to residents.

In a study the extent to which this new method yielded results consistent with the existing research, and also to investigate its potential for opening up new insights concerning the connotations of colour.

5. Conclusion

This study illustrates the experience of grief and loss of RNs working in RACFs. It demonstrates the value of arts‐based methods in capturing complex experiences. The use of colour and symbolism in artworks illustrates the interplay between grief and broader cultural narratives surrounding death. Findings suggest provision of education regarding emotional intelligence and empathy may mitigate emotional contagion leading to increased wellbeing of residents and improved levels of absenteeism and retention of RNs working in RACFs.

6. Relevance for Clinical Practice

This research advances understanding of grief and bereavement among nurses in RACFs by introducing arts‐based methods as a powerful approach to exploring emotional experience. Through creative expression using colour, symbolism, and imagery, the study captures the emotional and spiritual dimensions of grief that extend beyond what verbal reflection alone can reveal. The findings demonstrate how artistic processes facilitate emotional processing, self‐awareness, and meaning‐making, offering nurses a therapeutic outlet for coping with loss. By integrating these creative approaches into professional development and organisational wellbeing programs, the study provides a model for enhancing emotional resilience, reducing burnout, and improving staff retention in aged care. Furthermore, it contributes to the field of mental health nursing by evidencing the value of arts‐based methods in supporting psychological wellbeing, reflective practice, and compassionate care across clinical contexts, reinforcing the importance of nurturing both emotional and professional sustainability in the nursing workforce.

Author Contributions

M.S. and J.R. designed the study. M.S., M.G., and C.S. collected the data. M.S. and J.R. analysed the data. M.S. prepared the manuscript. All authors approved the final version for submission.

Funding

This work was supported via Seed Funding by the University of Newcastle.

Ethics Statement

Ethical approval was obtained from a university ethics committee (H‐2022‐0348).

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Drawing/Painting Materials

Appendix B. Art Activity Script

Is this the 1st time completing an art‐based activity?

□ Yes

□ No

‘I would like to ask you to complete an artwork. Please know that you do not have to be an artist, all I ask is that you express your own experience using the material provided. There are no right or wrong artworks/images. Any artwork/image you create is simply an expression of your feelings and thoughts. Please reflect on your time working as an RN in a RACFs. Reflect on your experience of grief, loss and bereavement. I would like to ask you to make an artwork of what that experience means to you. This could be your feelings or thoughts, an actual event, the outcome, your body; it can be abstract or literal. It can be anything you want it to be. Please feel free to use any combination of the materials here. If you become uncomfortable at any time, please let me know and we will stop the activity. To give you some space and time, I will move to the other end of the desk and do some of my own work’.

Semi‐structured script for artwork/image descriptions post art activity have been adapted from Rose's critical visual methodology framework (Rose 2016) (in italics):

‘Let's talk about your image/s. Can you describe what you have drawn in detail for me’.

Topic	Question
Content of the image	What meaning does the artwork hold for you?
	What was the first thing drawn/painted/sketched in the image?
	What thought was behind the first element?
Representations of the image	What does this specific aspect of the artwork represent?
	Why did you choose to draw this particular image?
Colours in the image	What influenced you to use certain colours?
	Do the colours represent something specific?
Orientation of the image	Why did you choose to draw the image this way?
Thoughts on the image	What does your artwork mean to you?
Feelings on the image	What do you feel when you look at your image?
	Would you like to provide a statement about your art?

‘Thank you for your time today’.

Appendix C. Arts‐Based Research

Arts‐based research is a data collection method utilised to explore and convey human experiences (Baden and Wimpenny 2014). Arts‐based research involves using drawing and painting to depict observable forms that express thoughts, feelings, or concepts, encapsulating both cognitive and emotional representations (Muhr 2020). Studies investigating chronic diseases (Stubbs et al. 2021; Cheung et al. 2018; Besser et al. 2012; Broadbent et al. 2009) have expressed rich value in arts‐based research. This approach increases understanding by offering extensive contextualisation and immersion in an individual's life experience (Barone and Eisner 2012; Leavy 2018). This may be particularly important to gain insight into registered nurses working in residential aged care facilities that is complicated by repeated exposure to death. In order to fully describe this impact, it is necessary to use a methodology that comprehensively assesses this dimension of the individual's experience.

Stubbs, M. , Gaviola M., Sunner C., and Reis J.. 2026. “Articulating Grief: Arts‐Based Therapy as a Pathway to Resilience in Nursing Practice.” International Journal of Mental Health Nursing 35, no. 1: e70218. 10.1111/inm.70218.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.