Cuidados enfermeros en el duelo perinatal. Una revisión sistemática y crítica de las actitudes y los conocimientos en la práctica clínica / Nursing care in perinatal grief. A systematic and critical review of attitudes and knowledge in clinical practice

Objetivo: Revisar y sintetizar la evidencia disponible sobre las actitudes y conocimientos de las enfermeras ante el duelo perinatal de los progenitores. Método: Se realizó una revisión sistemática de artículos originales publicados desde enero del 2016 hasta febrero del 2023, sin límite de idioma, en las bases de datos Scopus, PubMed, Cinahl, PsycINFO, ScienceDirect y Web Of Science. Se utilizó el marco metodológico de la Declaración Preferred Reporting Items for Systematic reviews and Meta-Analyse (PRISMA) para revisiones sistemáticas y metaanálisis. Todo el proceso se efectuó por pares, siendo solventadas las discrepancias por un tercer revisor. Se evaluó la calidad de los artículos siguiendo los criterios Critical Appraisal Skills Programme Español (CASPe). Resultados: Se obtuvieron 12 artículos en esta revisión tras aplicar los criterios de inclusión, de los cuales, salvo un estudio cuantitativo transversal (8,33%), los demás eran análisis cualitativos realizados mediante entrevistas (75%) o grupos de discusión (16,66%). Se destaca que existen diferentes problemas biopsicosociales relacionados con las necesidades de cuidado que demanda la familia y que, por escasa formación o cultura del profesional sanitario, no se abordan de una manera adecuada. Los estudios encontrados muestran diversos recursos para atender adecuadamente el duelo perinatal, existiendo discrepancias en relación con permitir o no que se muestre y/o coja el cuerpo del bebé fallecido; existen también desacuerdos respecto a si el equipo asistencial debe fundamentar su práctica en protocolos o teorías como la del duelo de Kübler-Ross. La mayoría de los estudios (75%) consideran necesarias más formación y sensibilización contemplando la naturaleza biopsicosocial del usuario.(AU)

Aim: To review and synthesize the available evidence on the attitudes and knowledge of nurses regarding the perinatal grief of the parents. Methods: A systematic review of original articles published from January 2016 to February 2023 without language limit in the Scopus, PubMed, Cinahl, PsycINFO, ScienceDirect and Web Of Science databases was carried out. The PRISMA Statement methodological framework was used for systematic reviews and meta-analyses. The entire process was carried out in pairs, with discrepancies being resolved by a third reviewer. The quality of the articles was evaluated following the Critical Appraisal Skills Program Spanish (CASPe criteria). Results: Twelve articles were obtained in this review after applying the inclusion criteria, of which. Except for one cross-sectional quantitative study (8.33%), the rest were qualitative studies carried out through interviews (75%) or discussion groups (16.66%). It is highlighted that there are different biopsychosocial problems related to the care needs demanded by the family and that, due to poor training or culture of the health professional, are not adequately addressed. The studies found show various resources to adequately attend to perinatal grief, there being discrepancies in relation to allowing or not allowing the body of the deceased baby to be shown and/or taken; There are also disagreements regarding whether the healthcare team should base its practice on protocols or theories such as the Kübler-Ross theory of grief. Most of the studies (75%) consider that more training and awareness is necessary, contemplating the biopsychosocial nature of the user.(AU)

Compulsory separation of women prisoners from their babies following childbirth: Uncertainty, loss and disenfranchised grief.

There is growing evidence to show increased mental ill health in women compulsorily separated from their babies at birth (Cantwell et al., MBRRACE-UK, 2018:56). For imprisoned women, the risk of self-harm and suicide may be exacerbated. This article draws on in-depth interviews with a sample of 28 imprisoned pregnant women/new mothers, 10 prison staff and observations to discuss the experience of separation from or anticipation of separation of women from their babies. Oakley (Signs, 4:607-631, 1980) reflected on the transition to motherhood with reference to the sociology of loss of identity. Women who have been compulsorily separated from their babies experience subjugated loss out of place with societal norms. The experiences of compulsory separation, in relation to concepts of disenfranchised grief, resonate with Lovell's (Social Science & Medicine, 17:755-761, 1983) research into the altered identities of mothers when loss occurs through late miscarriage or stillbirth. Additionally, this type of complex loss also denies a woman her identity as a 'mother'. This article offers a fresh sociological perspective on the ways loss and grief are experienced by women facing separation from their babies in prison, drawing on concepts of uncertainty, loss and disenfranchised grief.

"Living in the Darkness": Technology-Facilitated Coercive Control, Disenfranchised Grief, and Institutional Betrayal.

This article draws on interviews with 20 Australian women subjected to technology-facilitated coercive control (TFCC), foregrounding their accounts of grief and institutional betrayal. Findings show that while the harms of TFCC were significant, survivors' experiences were often minimized and dismissed by justice institutions. Women experienced grief due to abuse and separation from partners who had betrayed them. This loss was compounded when seeking help. We propose that disenfranchised grief is an underexplored response to domestic violence and institutional betrayal as well as a potential intervention site, particularly in relation to technology-facilitated abuse.

O luto não reconhecido pela morte do animal de estimação: Um estudo com tutoras de animais na cidade de Canguçu-RS / Unrecognized grief after the pet's death: A study with animal tutors in the city of Canguçu-RS / Dolor no reconocido por la muerte de la mascota: Un estudio con tutores de animales en la ciudad de Canguçu-RS

O objetivo desta pesquisa foi o de investigar a existência de impactos psicoló-gicos resultantes do não reconhecimento do luto pela perda de um animal de estimação. Trata-se de um estudo de caso com uma abordagem qualitativa. A pesquisa foi desenvolvida na cidade de Canguçu, na região sul do estado do Rio Grande do Sul. Fizeram parte do estudo 5 pessoas do sexo feminino, com idades entre 30 e 60 anos, que tiveram a perda de um animal de estimação nos últimos 12 meses. Essa amostra foi escolhida de forma aleatória, oriunda dos cadastros de duas clínicas veterinárias do município. Todas as participantes foram convidadas ao estudo, autorizando através do termo de Consentimento Livre Esclarecido sua participação. Foi utilizada uma entrevista semiestrutu-rada, a qual foi gravada e os áudios das mesmas foram transcritos, os dados obtidos foram analisados e divididos em categorias. Este estudo foi aprovado por comitê de ética em pesquisa. Os resultados obtidos evidenciam que, em relação ao reconhecimento social, ficou evidente a falta de empatia por parte da sociedade, não legitimando esse pesar. Notam-se alguns impactos significativos pelo não reconhecimento do luto, como isolamento, receio, tristeza, culpa, dor por esconder seu sofrimento e sentimento de incompreensão.

The objective of this research is to investigate the existence of psychological impacts resulting from not recognizing grief after the loss of a pet. This is a case study with a qualitative approach. The research was carried out in the city of Canguçu in the southern region of Rio Grande do Sul, in Brazil. The study featured 5 women aged between 30 and 60 years old, who had lost a pet in the previous 12 months. This sample was randomly chosen, from the records of two veterinary clinics in the city. All participants were invited to participate in the study, authorizing it through the Informed Consent form. A semi-structured interview was conducted, which was recorded, and audio from the interviews was transcribed, while obtained data were analyzed and divided into catego-ries. This study was approved by a research ethics committee. The obtained results show that in relation to social recognition, the lack of empathy from society was evident, not legitimizing this type of grief. There are some signi-ficant impacts due to the failure in recognizing grief, such as: isolation, fear, sadness, guilt, pain for hiding their suffering and feeling of incomprehension.

El objetivo de esta investigación fue investigar la existencia de impactos psicoló-gicos derivados de no reconocer el duelo por la pérdida de una mascota. Este es un estudio de caso con un enfoque cualitativo. La investigación se realizó en la ciudad de Canguçu en la región sur de Rio Grande do Sul. El estudio incluyó a 5 mujeres de entre 30 y 60 años, que habían perdido una mascota en los últimos 12 meses. Esta muestra se eligió al azar, de los registros de dos clínicas veteri-narias de la ciudad. Todos los participantes fueron invitados a participar en el estudio, autorizándolo a través del formulario de Consentimiento Informado. Se utilizó una entrevista semiestructurada, en la cual se grabó y se transcribieron los audios de las entrevistas, se analizaron los datos obtenidos y se dividieron en categorías. Este estudio fue aprobado por un comité de ética en investigación. Los resultados obtenidos muestran qué en relación al reconocimiento social, la falta de empatía por parte de la sociedad fue evidente, no legitimando este duelo. Existen algunos impactos significativos por la falta de reconocimiento del duelo, tales como: aislamiento, miedo, tristeza, culpa, dolor por ocultar su sufrimiento y sentimiento de incomprensión.

Prognosticating COVID Therapeutic Responses: Ambiguous Loss and Disenfranchised Grief.

Conventionally, therapeutic assessments, interventions, and treatments have focussed on death-related "losses and grief" responses. It is purported that the COVID-19 aftermath has resulted in losses that cannot always be encapsulated using this method. In search of reasoning, models and theories that explain the sweeping mass destruction that COVID-19 has caused, key concepts arise in terms of how we should deal with losses and in turn support patients in the health and social care sector, (notwithstanding formal therapeutic services). There is a crucial need to embrace ambiguous loss and disenfranchised grief into everyday terminology and be acquainted with these issues, thereby adapting how services/clinicians now embrace loss and grief work. Integral to this process is to recognize that there has been a disproportionate impact on Black and minority ethnic communities, and we now need to ensure services are "seriously culturally competent." Primary Care services/IAPT/health and social care/voluntary sector are all likely to be at the forefront of delivering these interventions and are already established gatekeepers. So, this article discusses the prognostic therapeutic response to non-death related losses and grief, not restricted to the formal echelons of therapeutic provision.

Disenfranchised grief and Covid-19: How do we make it less painful?

The devastating effects of death due to Covid-19 on the bereaved are not adequately addressed. The grief associated with death during the Covid-19 pandemic is disenfranchised and complicated and has significant repercussions on the bereaved. The lockdown, social distancing norms, isolation due to disease or quarantine and infectivity of the disease, place restrictions on the traditional mourning practices. Misconceptions also play a role. Dignity and ethics are frequently breached, perhaps inadvertently. This can lead to serious mental and physical health consequences. We explore the complexities and suggest measures for acknowledging the grief and making it less painful. Pragmatic suggestions to avoid emotional distancing and to uphold the dignity and rights of the deceased and the bereaved are highlighted with examples which can be emulated.

Grief: The Epidemic Within an Epidemic.

COVID-19 has not only dramatically changed the way we live, it has also impacted how we die and how we grieve. With more and more Americans dying in ICU settings, away from family, and more funerals being held virtually, the pandemic has seriously curtailed normal expressions of grief and cultural mourning. Given the CDC guidelines for funerals and social distancing, simple human touch is no longer a mitigating force against prolonged grief. So, while one epidemic has a face and a name, we point to a second, more silent yet potentially equally devastating one, unacknowledged grief, and emphasize how policy can be a current therapeutic. We can wait for a vaccine, but we can also act now through thoughtful policymaking that acknowledges this second epidemic.

Disenfranchised Grief and Families' Experiences of Death After Police Contact in the United States.

This article examines the experiences of family members when a loved one dies after police contact in the United States. It uses qualitative data from semistructured interviews with the bereaved families of 43 U.S. citizens who died after police contact and considers their experiences as covictims of homicide. It examines how they experience grief in the aftermath of such a death and considers Doka's concept of disenfranchised grief in evaluating how social norms affect their grieving process. It argues that individuals affected by deaths after police contact are often unable to grieve in a way that is socially legitimized. The article finds that disenfranchised grief has a racial dimension with regard to deaths after police contact with non-White families being deeply affected by it due to their position within society, the context in which their loved one died, and in terms of how the deceased was socially constructed.

A Nonheroic Cancer Narrative: Body Deterioration, Grief, Disenfranchised Grief, and Growth.

This longitudinal nonheroic narrative study allows familiarity with personal and societal transitions in the self-identity of individuals with life-threatening cancer. The theoretical anchor is Bion's container-contained theory. Five interviews with a terminally ill hospitalized male in his 30s were conducted along intervals of between 6 and 8 weeks, up to 2 months before his death. Data were analyzed using the selection mechanisms method. Findings provide insights about the hospitalization experience, his grief, and disenfranchised grief. A rigid mode of container-contained relationships with clinicians created disenfranchised grief. Reflection and coherence among self-identities lead to inner strength and emotional growth despite the body's deterioration. Clinicians have a role in holistic identity transitions of individuals with cancer. Findings illuminate practical recommendations that clinicians may adopt to improve the experience of individuals suffering from cancer at the chronic and terminal phase of illness.

El duelo en tiempos de pandemia: la muerte escrita / Grief in times of pandemic: written death

En tiempos de pandemia los rituales funerarios quedan alterados y en ciertos sitios, suprimidos. los alcances subjetivos de este impedimento no son todavía visibles. No obstante, la formas de despedida y acompañamiento no quedan canceladas. La palabra encuentra los modos de alojar al dolor mostrado su eficacia en el campo de lo humano. Es necesario acentuar estos modos vicarios de la despedida porque de ellos depende el destino del duelo mismo

In times of pandemic, funeral rituals are altered and, in certain places, suppressed. the subjective implications of this impediment are not yet visible. However, the forms of farewell and accompaniment are not canceled. The word finds ways to accommodate pain by showing its effectiveness in the field of the human. It is necessary to accentuate these vicarious ways of parting because the fate of the duel itself depends on them

"Es algo que no se cuenta": relatos sobre pérdidas gestacionales en Youtube / "It's something you don't talk about": miscarriage testimonies on Youtube

OBJETIVO: Analizar el contenido de los videos testimoniales sobre pérdidas gestacionales en Youtube en español para poder concluir si las narrativas se enmarcan en la lógica biomédica moderna o posmoderna de vivir esta situación de acuerdo a los postulados de Frank y Bauman. MÉTODOS: Búsqueda sistemática de los vídeos en español desde 2011 a mayo de 2019, que contuvieran en su título las palabras clave "aborto" o "perdida gestacional", y que tuvieran más de 100.000 visualizaciones en Youtube desde su publicación, como criterios de inclusión. Visualización de los vídeos para su posterior análisis de contenido para detallar las características del canal, los motivos para contar la experiencia, el momento en que se cuentan, la interacción existente con las seguidoras, las etapas que se narran sobre el suceso y el lenguaje utilizado para relatarlo. RESULTADOS: Se encontraron nueve youtubers que cumplieron los criterios de inclusión, y un total de diez vídeos que recogían relatos sobre pérdidas gestacionales. Sólo dos de los nueve canales estaban centrados exclusivamente en la maternidad. Los relatos se inscriben en una lógica biomédica posmoderna, por la necesidad manifiesta de explicar el suceso online, el reconocimiento de la fase del duelo, y la poca presencia del lenguaje de la supervivencia. CONCLUSIONES: Este estudio muestra que la necesidad de explicar la experiencia online responde a la decisión de visibilizarla y de servir de apoyo a otras mujeres. Los resultados de este estudio pueden ser de utilidad para los/as profesionales de Enfermería que en su práctica clínica tienen contacto directo con las mujeres que han sufrido pérdidas gestacionales

OBJECTIVE: To analyze the content of testimonial videos about pregnancy loss in Spanish on YouTube, so as to explore whether such narratives are framed in relation to the modern or postmodern biomedical logic of this experience as formulated by Frank and Bauman. METHODS: Systematic search of videos in Spanish from 2011 to May 2019, using the following inclusion criteria: contain the key words miscarriage or pregnancy loss in their title and have had more than 100,000 views on YouTube since their publication. To enable further content analysis, the videos were viewed to detail the characteristics of the publication channel in each case and to catalog their contents in terms of reasons for talking about the experience, the time chosen to tell the story, interaction with followers, the stages in the narrative, and the language used. RESULTS: We identified nine YouTubers that met the inclusion criteria, comprising a total of ten videos. Only two of the nine channels focused exclusively on motherhood. The stories are inscribed in a postmodern biomedical logic, due to the clear need to explain the traumatic event online, the recognition of the grief phase, and the limited use of survival language. CONCLUSIONS: This study shows that the need to talk about the experience online is motivated by a decision to make the experience visible and offer support to other women. The results of this study may be useful to nursing professionals whose clinical practice involves caring for women who have suffered pregnancy loss

Prolonged grief related to COVID-19 deaths: Do we have to fear a steep rise in traumatic and disenfranchised griefs?

The circumstances of coronavirus disease (COVID-19)-related deaths embed multiple traumatic characteristics, alongside several external factors that can disenfranchise individual grief. In this context, severe forms of traumatic distress, guilt, somatization, regret, anger, and unspecific symptoms not yet included in prolonged grief disorder (PGD) criteria could emerge. This article (a) analyzes factors related to bereavement in the context of the COVID-19 pandemic; (b) proposes avenues for meaning-making practices to facilitate individual and collective mourning process; and (c) invites clinicians to pay attention to the traumatic characteristics of COVID-19-related deaths adopting a holistic approach of PGD clinical manifestations, as well as in evaluation and treatment of cases. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Loss and grief amidst COVID-19: A path to adaptation and resilience.

The COVID-19 pandemic has posed an extreme threat to global health and become a leading cause of death worldwide. Loss, as a more encompassing theme, interweaves many aspects of people's life in this challenging time. Failure to address the pressing needs of those experiencing loss and grief may result in poor mental and physical health. Recognizing the uniqueness of each individual and their loss and grief will provide opportunities to develop tailored strategies that facilitate functional adaptation to loss and promote mental health and wellbeing in this crisis.

Exploring the loss and disenfranchised grief of animal care workers.

This article explores the psychological distress of Animal Care Workers (ACWs), and the disenfranchisement of this distress through mixed methods study conducted as an online survey. In all, 139 participants responded about their experiences as an ACW, related psychological distress, and the systemic disenfranchisement of distress. Findings indicate that nearly half of ACWs experienced symptoms of depression in the previous month. Over 66% indicated it was difficult to cope. Limited support often resulted in a disenfranchized loss. Implications suggest ACW distress and disenfranchisement related to animals they serve is similar to that of individuals who lose animal companions.

Paying your respects: Transgender women and detransitioning after death.

This paper asks how do the deaths and the postmortem detransitioning (the verbal, visual, and material rejection of a person's gender identity) of transgender women impact trans activism? After analyzing the case studies of Jennifer Gable and Leelah Alcorn, I outline how the contentious memorialization of transgender women and the disenfranchized grief of survivors influence trans activism. I conclude that activism is characterized by respecting the wishes of the deceased, by preventing the violence which transgender women experience, by advocating for trans elder care, by educating about end-of-life issues, and by lobbying for laws that protect transgender men and women after death.

Disadvantaged and disenfranchised in bereavement: A scoping review of social and structural inequity following expected death.

An emphasis on individual intervention and psychological complexity has characterised research on bereavement following an experience of life-limiting illness. Exploration of "structural vulnerability" as a positionality produced by social and structural inequity could provide insights into areas of practice and policy in need of development. This scoping review sought to summarise published research on experiences of social and structural inequities in the context of bereavement due to life-limiting illness. Underpinned by recognised methodological frameworks, systematic searches were conducted of four electronic databases. Eligible studies attended to bereavement experience following the death of an adult due to life-limiting illness, included consideration of social and structural inequities, and were undertaken in high income countries between 1990 and 2018. Following thematic analysis, a conceptual framework was developed. Of 322 records, 62 full text articles were retrieved and 15 papers met inclusion criteria. Studies highlighted unequal social status in bereavement related to gender, class, sexuality, ethnicity and age, with structural inequity experienced in interactions with institutions and social networks. Studies also identified that the experience of bereavement itself may be accompanied by exposure to disenfranchising systems and processes. Structural vulnerability appeared to be associated with outcomes including psychological distress, social disenfranchisement and practical concerns such as financial strain, housing insecurity and employment issues. Social and structural inequities potentially contribute to layered and patterned experiences of disadvantage and disenfranchisement following expected death, with implications for individual agency. Findings point to the need for consideration of socio-ecological approaches within and beyond specialist palliative care, involving development of more responsive social policy, coordinated advocacy, and systemic capacity building regarding experiences of grief, to better support populations positioned as structurally vulnerable in bereavement.

Quando morre o animal de estimação: um estudo sobre luto / When a pet dies: a study about mourning / Cuando muere el pet: un estudio de luto

Este escrito resultou de pesquisa realizada com pessoas que perderam seus animais de estimação em decorrência de morte. A sua realização teve como objetivo a compreensão do processo de enfrentamento do luto vivenciado por essas pessoas, ao experimentarem as perdas dos seus animais de estimação. Para isso, valeu-se do enfoque qualitativo, empregandose entrevistas semiestruturadas, e recorreu-se a fundamentos da teoria do apego, de John Bowlby, e das tarefas do luto, de W. Worden, para a análise dos dados colhidos. Com base nessas referências, foi possível concluir que os participantes da pesquisa estabeleceram fortes vínculos de apego com seus animais de estimação, bastante semelhantes àqueles construídos com seres humanos. Pode-se concluir que, devido a essas fortes vinculações, nas quais foram depositadas intensas expectativas de ordem afetiva, todos os processos de luto vivenciados por essas pessoas apresentaram características semelhantes àquelas presentes em processos de luto decorrentes da perda de pessoas significativas.

This study is the result of a survey carried out among people whose pets had died. The objective was to understand the process of facing the loss of their pets. A qualitative approach with semi-structured interviews, applying some fundamentals from John Bowlby’s attachment theory and W. Worden’s mourning tasks were tools used for the analysis of the collected data. According to these references, it was possible to conclude that the survey participants established strong attachment bonds with their pets, quite similar to those present in human beings. It can be concluded that, due to these strong attachments in which intense expectations of affective nature were filled, all the processes of grief that were experienced by the subjects had the similar characteristics to those presented in the mourning processes arising from the loss of meaningful people.

Este trabajo trata de un estudio sobre las personas que han perdido sus mascotas debido a la muerte. Tiene como objetivo comprender el proceso del duelo vivido por estas personas. Para esto, fue utilizado el enfoque cualitativo, mediante entrevistas semiestructuradas, y se recurrió a los fundamentos de la teoría del apego de John Bowlby y del proceso del duelo y sus tareas de W. Worden para el análisis de los datos recolectados. A partir de estas referencias, se concluye que los participantes de la investigación establecen vínculos afectivos con sus animales domésticos bastante similares a los construidos con los seres humanos. Debido a estos vínculos fuertes, en el que se depositan las expectativas de intensas relaciones afectivas, los procesos de duelo que experimentan estas personas tienen características similares a aquellos que resultan de la pérdida de personas significativas.

Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary.

BACKGROUND: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement. OBJECTIVE: To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs. SEARCH STRATEGY: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL. SELECTION CRITERIA: Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs. DATA COLLECTION AND ANALYSIS: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES). MAIN RESULTS: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth. CONCLUSIONS: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately. TWEETABLE ABSTRACT: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Home Care Workers' Experiences of Client Death and Disenfranchised Grief.

While many types of health care workers experience patient death, home care workers do so under vastly different social and economic circumstances. When a client dies, home care workers often lose both a close relationship and a job. Though research suggests that health care workers' grief may frequently be disenfranchised, there is no in-depth study of the mechanisms that disenfranchise home care workers' grief specifically. To address this gap, our study used focus groups and peer interviews between home care workers in New York City. We describe four interrelated grief strategies they employ to navigate social and employer-based "grieving rules." Our findings suggest that home care workers' grief is disenfranchised via employer and societal underestimations of their relationships with clients and their losses when clients die, particularly job loss. Building on our findings, we suggest alterations to agency practices and home care systems to improve support for workers.