The Use of Garden Memorial Ritual for Survivors, Families, and Healthcare Workers as a Result of the COVID-19 Pandemic in Nursing Facilities

Abstract

Over the course of the last year and a half, the Coronavirus has swept across the world causing death and devastation to our geriatric population residing in long term care facilities, also known as nursing homes. This paper explores the complicated grief responses exhibited by individuals who were affected by nursing home resident COVID-19 deaths. Nursing home resident survivors, families of the deceased residents, and healthcare workers in this situation have experienced a wide variety of complicated grief responses that need to be addressed. To address this need, an application will follow regarding the usage of a garden memorial ritual and ceremony to help these grievers in their first steps of mourning.

In late winter of 2020, the Coronavirus, also known as COVID-19, spread across the entire world forcing people of all nations to adapt to a new way of life focused on guidelines that included isolation, mask wearing, and social distancing. Unfortunately, these guidelines did not come quickly enough, resulting in one of our most vulnerable and diverse populations being severely affected by this deadly virus. Resident deaths within nursing home facilities made up the majority of the victims who perished from this virus, resulting in many nursing facilities around the world becoming ghost towns. The results of this traumatic event have left many surviving residents, families of lost loved ones, and healthcare workers that work within these facilities in a state of traumatic grief and bereavement. This paper discusses what occurred in these nursing facilities during the pandemic, explores how these deaths have affected loved ones of the deceased, and concludes with how the use of a garden memorial ritual can help the survivors find closure and work through the remaining processes of their grief and bereavement.

Nursing Facilities During COVID-19

On February 29, 2020, a nursing home in Washington state was the first nursing facility in the United States to report an outbreak of the Coronavirus (American Health Care Association, 2021). This outbreak started the epidemic within nursing homes around the country falling victim to their own outbreaks. According to the Centers for Disease Control (CDC) and the World Health Organization (WHO), the Coronavirus is a virus that is caused by SARS-CoV-2 (CDC, 2021; WHO, 2021). Excluding the elderly, most populations who contract the disease experience only mild symptoms. The elderly, however, who naturally may have one or many underlying medical conditions or chronic illnesses, are at higher risk of becoming seriously ill or dying from the virus. (CDC, 2021).

The Coronavirus is understood to spread easily through close person to person contact in less than six feet of distancing (CDC, 2021). The (CDC and WHO [2021]) concluded in early to mid-spring of 2020 to make the recommendations of universal social distancing and masking to help curb the spread of the Coronavirus. In addition to these guidelines, nursing facilities were recommended, and in some states required, to close their doors for visitation in an effort to reduce exposure and infection (American Health Care Association, 2021; CDC, 2021). However, in most areas these recommendations came too late, and great percentages of nursing home residents were already infected or soon to be infected.

Within these nursing homes, residents were separated from their families and friends while battling this disease and in some cases died alone without the comfort of their loved ones (Graham, 2021; Kosofsky, 2021). As for the staff members who worked in these facilities, they were often overworked and infected themselves by the virus, creating understaffing in facilities when help was in dire need. As of June 1, 2021, it is estimated “at least 184,000 Coronavirus deaths have been reported among residents and employees of nursing homes and other long-term care facilities in the United States… the virus has infected more than 1,383,000 people at some 32,000 facilities” (New York Times Database, 2021, para. 1). The total deaths are estimated to be higher due to the secondary effects of post-COVID-19 conditions that have killed additional residents in these facilities. According to the (CDC (2021)), these deaths are not counted toward the total number of deaths since the COVID-19 virus would be out of the individual’s system and no longer be directly attributed to cause of death.

Survivors, Families, and Healthcare Workers Grief Reactions

After the traumatic deaths of so many residents in nursing facilities, resident survivors, families of the deceased, and healthcare workers that work in these facilities were forever changed by these losses. These secondary victims of COVID-19 are reporting higher rates of traumatic bereavement by exhibiting symptoms of traumatic stress, including helplessness, anxiety, sadness, horror, guilt, anger, and regret (CDC, 2020; Graham, 2020b).

Resident Survivors

Resident survivors lost friends and roommates, and their sense of community was destroyed (Pappas, 2021). One resident who lost their roommate of 2 years to COVID-19 reported “You keep a lot inside and you don’t show it on the outside… You feel safe here and then it shatters your sense of security, and you notice there is no such thing” (Kosofsky, 2021, para. 1). Over the last year, it has been reported that the need for mental health services and grief counseling services for resident survivors have increased exponentially, but because of the strict closure guidelines set for most of the year, adequate support could rarely be provided (CDC, 2021; Graham, 2020a; pappas, 2021).

According to Yelena Zatvolovsky, vice president of patient experience at Seasons Hospice and Palliative Care, the grief reactions exhibited by the surviving residents in nursing facilities have become far more intense and challenging (Graham, 2020b). She goes on to say, “it’s not just the people who die on hospice and their families who need bereavement support at this time; it’s entire communities” (Graham, 2020a, para. 17). Altarum, a research group, conducted a survey of over 365 residents in different nursing homes that asked about their recent experience living in a nursing home in the last year. Many residents commented about the deaths of other residents, and there was a collective cry for help both emotionally and psychologically. “I am completely isolated. I might as well be buried already”, “There is no hope.“, and “I feel like giving up… No emotional support nor mental health support is available to me” (Graham, 2020b, para. 17).

Families of the Deceased

As for the families of COVID-19 victims, their grief responses are complicated as well. These family members have lost spouses, parents, grandparents, and siblings. It is estimated that nine close family members for every person who dies from COVID-19 are affected by the loss (Graham, 2020a). Prior to the COVID-19 crisis, it was estimated that five to 10% of family members suffered from traumatic bereavement. Most recently, these statistics have grown to 40%. For the surviving spouses and children of COVID-19 victims in nursing homes, extreme guilt, regret, and anger are the most prominent grief reactions (Graham, 2020a; Kosofsky, 2021).

These kinds of feelings stem from close family members being unable to be with their loved one as they died. One spouse of a deceased nursing home victim stated, “We always promised each other that we wouldn’t let each other die alone, but nobody saw this coming” (Kosofsky, 2021, para. 7). Many surviving families are often left wondering and worrying about the events that led up to their loved one’s death, questioning if their loved one was comfortable and at peace. Such thoughts have left many children of COVID-19 victims with an immense amount of guilt and regret regarding their decision to place their parents into a nursing facility. “There have been a lot of ‘What ifs?’ and some anger: Someone or something needs to be blamed for what happened” (Graham, 2020b, para 24).

Healthcare Workers

Many nursing home residents consider the various healthcare workers who take care of them directly, support them, and manage their home as family and a major part of their community. During the height of the pandemic, many nursing home healthcare workers were stressed and overworked as they provided the needed care for their residents (Bartoldus et al., 2020; Graham, 2020a). Death is very common in nursing homes, but these deaths are almost always very personal to the workers, who sometimes consider the residents as their family. The COVID-19 pandemic quickly caused many outside individuals and families of deceased residents to blame nursing home workers for spreading the disease to their loved ones, further complicating their grief by creating disenfranchised grief (Ayer, 2021; Bartoldus et al., 2020; Graham, 2020b).

Given the sheer number of resident deaths and the added mental strain of public shaming, many healthcare workers reported extreme levels of fear and anxiety. “‘I get so depressed seeing so many residents die.’ and ‘I am so afraid I will be the one to bring the virus into my nursing home’” (Bartoldus et al., 2020, para. 1). One worker recounted “The phone rang at 1 a.m. and all I heard on the other end was an administrator sobbing… She said she felt she was emotionally falling apart. She felt like she was responsible for the residents who had died, like she had let them down” (Graham, 2020a, para, 23).

Usage of Ritual: Garden Memorial and Ceremony

Due to the many restrictions imposed during the COVID-19 pandemic, resident survivors, families of the deceased, and healthcare workers within nursing home facilities could not be part of or participate in regular or custom rituals after the immediate deaths of residents. Subsequently, many of these people are still in a state of traumatic bereavement (Graham, 2020b). Since the release of the COVID-19 vaccines and the steady decline of infections in the late spring of 2021, it is necessary that these people are given the opportunity to practice a ritual that will possibly help them work through the other processes of their bereavement response. The ritual that is being proposed for these individuals is a garden memorial and ceremony that would occur within nursing facilities.

As defined by Hans Penner of the Britannica, ritual is “the performance of ceremonial acts prescribed by tradition or by sacerdotal decree” (Penner, 2016, para. 1). Furthermore, according to Therese Rando, author of Treatment of Complicated Mourning, a ritual should be employed to help individual mourners find “a structured way to affirm the death, recall the loved one… they can assist the mourner in saying good-bye to the deceased” (Rando, 1993, p. 314). All of these processes have been taken away from mourners keeping many of them still in a state of shock or not yet accepting of the deaths. This leaves mourners stranded in Rando’s first stage of mourning where mourners are still working to recognize the loss (Farber et al., 2014; Rando, 1993).

There are several factors that play into why a garden memorial and ceremonial type ritual would be applicable and helpful for these groups of traumatically bereaved individuals. First and foremost, the surviving residents of these nursing homes feel they have lost a sense of community with the deaths of their fellow residents. This type of ritual would gather all the members of the remaining community together along with families of the deceased and healthcare workers to honor each resident who has passed away. The ceremony would occur at their outside courtyard or garden area that would be dedicated to the resident victims of COVID-19. A memorial garden and ceremony also allow each mourner the opportunity to apply symbolism to the death, which is very helpful in the mourning process (Farber et al., 2014; Rando, 1993). In this type of ritual of continuity, “symbolic acts permit the individual to define the relationship with the other, provide security by permitting the individual to know where she stands in the situation and help participants adjust to change” (Rando, 1993, p. 323). The nursing home community, in this case, would create a memorial garden where plants and flowers would be symbolic of the residents’ lives that were lost. Dr Leonard Perry writes that “creating memorial gardens promotes healing. Maintaining them is therapeutic. The gardens not only keep alive their memories, but also provide beauty to those who see them even if they don’t know whom they are remembering” (Perry, n.d., para. 12).

Finally, the use of ceremony in this ritual would be used at the dedication of the memorial garden. According to several researchers, it is known and understood that residents of nursing facilities and their families are religious or spiritual (Hamilton et al., 2009). “The importance of religious and spiritual needs is one of the approaches to death” for this specific population (Hamilton et al., 2009). The use of a religious or spiritual ceremony and continued use of this ritual is known to provide a coping resource to so many mourners of a traumatic death (Farber et al., 2014; Rando, 1993).

Conclusion

In conclusion, there is no doubt that the Coronavirus was responsible for traumatic death for many individuals in our nursing facilities. The surviving residents, families of the deceased, and healthcare workers within these facilities experienced forms of prolonged, traumatic, complicated, and disenfranchised grief that many have not been able to work through properly. The ritual of a memorial garden and ceremony within the facilities would provide an important opportunity for these individuals to work through their initial processes for their grief work. The COVID-19 pandemic destroyed the sense of community in many nursing facilities. A sense of community can be reestablished through the use of a memorial garden and ceremony as individuals gather to remember and honor the lives of lost loved ones.

Author Biography

Millersville University of Pennsylvania BASW 2020, Millersville University of Pennsylvania MSW 2022.

ORCID iD

Mary L. Hoffman https://orcid.org/0000-0003-1601-3765