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The Metaphor of "Family" in Staff Communication About Dying and Death

¹ Polisher Research Institute, Abramson Center for Jewish Life, North Wales, Pennsylvania.
² Department of Sociology & Anthropology, University of Maryland, Baltimore.

Address correspondence to Miriam S. Moss, Polisher Research Institute, Abramson Center for Jewish Life, 261 Old York Road, Suite 427, P.O. Box 728, Jenkintown, PA 19046-7128. E-mail: mmoss{at}abramsoncenter.org

	Abstract

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Objectives. Caregiving staff need to have a way to make sense out of the death and dying of nursing home residents. A range of cultural and institutional factors (e.g., disenfranchised grief; professional distance) thwart their expression of grief. This research examines the neglected area of staff's social construction of the meaning of their relationship with dying and deceased residents.

Methods. As part of a multisite ethnographic study of bereavement in long-term care, we analyzed themes in audiotranscribed in-depth qualitative interviews with 26 hands-on caregiving staff members (over two thirds were nurse's aides) in two religiously and culturally diverse nursing homes.

Results. A theme of family metaphor emerged as staff members spoke of family-like thoughts, feelings, and behaviors toward long-term residents. Staff members spontaneously told stories of deaths in their own families, and they described how the meanings of resident deaths and family deaths were interrelated.

Discussion. The family metaphor provides cultural scripts that enable staff to overcome barriers to the expression of grief. The family metaphor structures the meaning for staff of death and bereavement, and it provides a bridge between their work and personal experience.

THIS article examines how the metaphor of "family" is used by nursing home staff to personalize the meaning of resident death within the contexts of both their private and their work lives. In nursing homes, staff caregivers frequently interact with residents who are dying. The nursing home normally does little to provide support, structure, or rituals to guide its employees through this time. Moreover, the process of meaning-making is central to bereavement (Nadeau, 1998; Neimeyer, 2001). People who deal with death as part of their work must find some way to make sense out of dying and death. This article examines metaphor—specifically the metaphor of family—and explores its role as a cultural script for staff members in their relationships with residents at the end of life.

Overall, the topic of death in the nursing home is muted and avoided. Although increasing numbers of older people are living in nursing homes at the end of their lives (National Center for Health Statistics, 1998), the ways that staff members experience grief have received little attention and research in gerontology (M. S. Moss, 2001). Significant ethnographic studies in U.S. and United Kingdom nursing homes do not closely examine the grief of staff members in response to resident deaths (Gubrium, 1997; Hockey, 1990; Kayser-Jones, 1981; Savishinsky, 1991; Shemmings, 1996; Shield, 1988). This article, however, focuses on this underinvestigated topic.

We first examine the concept of metaphor, specifically the metaphor of family, as it potentially may help the staff to form the social construction of resident deaths. Next, we outline barriers to the expression of staff grief. We then provide case material to illustrate how the metaphor is used. Finally, we outline multiple ways that the metaphor of family plays a role in the responses of staff members to the end of life of residents.

The Metaphor of Family
A metaphor is "a figure of speech in which words that literally denote one kind of object or idea are used in place of another, suggesting a resemblance or analog" (Rosenblatt, 1994, p. 1). As Lakoff and Johnson (1980) noted, "Metaphor is pervasive in everyday life, not just in language but in thought and action" (p. 3). Much of human understanding of the world is constructed by metaphors (Schroots, Birren, & Kenyon, 1991). A metaphor can help to create new meanings and new perspectives; it is a way of taking what we know and applying it to a less well-understood area. Metaphors can enable us to understand human behavior and to explain feelings. "There are better or worse metaphors, more or less useful or effective metaphors, but no right or wrong ones. Metaphors always involve the highlighting of certain aspects of phenomena and the obscuring of others" (Schroots et al., 1991, p. 3).

Here we examine how a metaphor projects upon a primary subject (the relationships of staff members with nursing home residents at the end of life) and the associations and implications of a secondary subject (family relationships). The metaphor that emerges, the metaphor of family, is a socially constructed concept. Social construction is the process by which we arrive at an understanding of intersubjective reality through describing and explaining an experience in its social context (Gergen, 1985). Thus, social construction is the result of a person's active efforts to create meaning of an experience from personal and cultural resources. People construe and model what they see in the light of its meaning in their social world, and this process has consequences for behavior. The focus here is on the ways that staff members interpret as family-like their caregiving and their relationship with residents at the end of life. We explore the implications of the family metaphor for the grief and bereavement of staff members. As we suggest, the reaction of staff members to the dying and death of a resident is in part structured and understood in terms of a metaphor of family.

Barriers to Expression of Staff Grief
Broad social and cultural assumptions, as well as institutional values, contribute to the lack of understanding and support of caregiver grief. These include overarching themes of ageism and disenfranchised grief, as well as institutionally based themes of boundaries between living and dying, professional distance, power differentials between staff and residents, and lack of supportive rituals associated with dying, death, and bereavement.

Ageism is socially and culturally rooted and views older persons in negative terms (Butler, 1969; Rubinstein, 1995; Thompson, 1995). Through ageism, older people are viewed as homogenous and as frail, isolated, rigid, and sexless. Ageist perspectives overlook older people's pasts, their current feelings, competence, significance to others, and their multiple roles in the world. As a result, their deaths as well as their lives are devalued, and their deaths are rationalized as timely and fair (M. S. Moss & Moss, 1989).

Disenfranchised grief, closely linked to ageism, is "the grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported" (Doka, 1989, p. 4). Grief for deceased old persons, particularly nursing home residents, is often disenfranchised by society (M. S. Moss & Moss, 1989). Society has negative stereotypes of nursing home residents who have lived a long life and who are frail, dependent, and often demented (S. Z. Moss & Moss, 2002). The context in which death occurs is significant here because it helps shape the meaning of the experience (Charmaz, 1980). Death in nursing homes is structured to have minimum impact on ongoing patterns of work and on relationships in the facility.

Next, we examine some aspects of the structure and functioning in the nursing home that minimize the impact of dying and death and thwart the expression of staff grief. Overall, there is a strong, often impermeable boundary between living and dying in the nursing home (Gubrium, 1997; Hockey, 1990). Nursing home regulations developed by the Center for Medicare and Medicaid Services as well as by the Joint Commission on Accreditation of Health Care Organizations focus almost exclusively on living and pay little attention to dying and death. Concern and talk about end of life and death is generally avoided in long-term care facilities (M. S. Moss, 2001). As Hockey (1990) suggested, the goal is on "keeping them going," which obscures staff's "more covert task of supervising the process of dying and the event of death" (p. 115). This boundary in practice is not surprising, because literature and research in gerontology has, until recently, tended to ignore issues of death and end of life, whereas the domain of thanatology has often ignored death in old age (M. S. Moss, Moss, & Hansson, 2001).

Professional distance in nursing homes involves a stance of detachment, emphasizing self-control over expression of feelings (Menzies, 1961). It often discourages the development of close emotional relationships between caregivers and care receivers (Vachon, 1998). Nursing homes stress the importance of routine bed and body task performance (Gubrium, 1997). There are few institutional supports for emotional labor (Hochschild, 1983) as part of everyday caregiving. Rather, there is an expectation that staff members should control their expression of grief in order to be able to efficiently carry out their primary work responsibilities. In addition, the construct of professional distance challenges the propriety of a staff member's grief in the face of family grief. There appears to be a tension between the wishes of staff members to express their own grief and their acceptance of the primacy of family grief.

There are power differentials in caregiving. Dependency is a central theme in nursing homes (Shemmings, 1996). Residents depend on staff to meet their daily needs for care, to minimize their pain and discomfort, to help them maximize physical and cognitive functioning, and to support their emotional and social well-being (Henderson & Vesperi, 1995; Kane, Kane, & Ladd, 1998). Tied to this theme of dependency is the clear power differential between hands-on caregivers and residents. Residents often feel powerless to engage in socially desirable reciprocal exchange with staff (Gladstone & Wexler, 2002; Kayser-Jones, 1981; Shield, 1998). The result is that close relationships are thwarted, and when a resident dies, a staff member's feelings of grief are limited.

There is little research to contradict the early study by Owen, Fulton, and Markusen (1982–1983) that found a tendency not to mark the deaths of the very old with a wide range of customary funeral rituals. In a study of 121 nursing homes in Michigan, only about half had a staff member attend the viewing or funeral of a deceased resident, and only half sent a sympathy card on the death, and 98% had no visit, phone call, or written material to the bereaved family (Murphy, Hanrahan, & Luchins, 1997). In a national study, less than half of the nursing homes reported that they had any memorial service in the previous year (Moss, Braunschweig, & Rubinstein, 2002).

It is not surprising that caregiving staff members develop ways to move beyond the barriers that thwart their grief. We explore the metaphor of family, which is one way they use to support their emotional labor and empathic concerns for dying and deceased residents.

	Methods

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Research Sites
The data on which this article is based were gathered in a multiyear, multisite study of the cultural construction of death and dying in nursing homes entitled "Bereavement in Long-Term Care." Here we focus on two not-for-profit nursing homes, one Jewish and the other Catholic. The nursing homes were chosen to represent settings that are religiously and ethnically diverse. In each facility, we spent time on two skilled care nursing units that were not specialized to provide care for persons with dementia. Although each setting reflects its religious sponsorship, the facilities have much in common. In both sites there is a high level of care, clear hierarchy of staff, and there is limited opportunity for staff members to express their feelings about the loss of a resident.

All of the residents in the 538-bed Jewish home are Jewish. A full-time medical staff and an accredited hospital augment the nursing facility. A full-time rabbi is available for pastoral support and prayer for the residents and their families. Funerals are rarely held in the chapel. A memorial service, conducted by the rabbi, is held on the unit, primarily to allow the surviving residents and family members to share their memories of the deceased. Sometimes one or two floor staff members attend. Additionally, floor staff send a condolence card to the family.

In the 171-bed Catholic nursing home, most of the residents are Catholic and of Irish-American ethnicity. There are religious as well as lay staff members. Religious Sisters routinely offer prayer and support at the bedside of the dying resident. Staff members encourage family to spend private time with the dying or deceased resident. Most viewings and funerals are held in the home's chapel and are part of the daily mass. Some caregiving staff members attend the viewing to say goodbye to the resident and a few offer condolences to the family.

Sample
The data are interviews with 26 floor staff, 14 in the Jewish home and 12 in the Catholic home. Floor staff have the opportunity to develop the strongest interpersonal ties with residents because they provided most of the daily care. Informants include 18 certified nursing assistants (CNAs), 6 licensed practical nurses (LPNs), and 2 registered nurses (RNs). All but 2 are female; 20 are African American, and 6 are European American. Eighteen had worked in their respective nursing home for 5 years or more.

Data Collection
Data were gathered through formal ethnographic interviews that took an average of 45 min. Each was audiotaped and transcribed. Interviews were held by a full-time ethnographer and a full-time qualitative interviewer in rooms on the care floor where privacy was ensured.

We developed a list of questions as a guide for the research interviews. The topics focused on the meaning of working in a nursing home where deaths occur and the staff member's job responsibilities at the end of a resident's life. Respondents were asked to describe any resident who is dying, to tell the story of the most recent death of a resident, and to tell of any resident's death that affected them. They were also asked about good deaths and bad deaths, professional distance, patterns of communication about death in the nursing home, attendance at funerals or memorial services, attitude toward crying in front of bereaved family members, and how work in the nursing home affects other parts of their lives. It is very important to note that although the interview guidelines were broad ranging, we did not initiate any discussion about the families of staff members or about deaths of close persons outside the nursing home. Thus, all mentions of the metaphor of family were unsolicited.

Data Analysis
Standard methods of qualitative data analysis were used (Berg, 1995; Coffey & Atkinson, 1996; Silverman, 1997, 2001). Analysis proceeded as follows: Large-level coding or the first phase of coding began as soon as the transcript of the first interview was available. In this basic level of coding we asked, "What is salient in this material?" Our answers to this question yielded themes, patterns, and key words or ideas that formed initial categories. Large-scale coding occurred throughout the project. We also developed a series of more refined codes that enabled us to have better analytical insight into the transcripts. As Mishler (1986) pointed out, coding categories should be generated from meanings that are inherent in the data themselves. Several iterations of increasingly refined coding were performed as new questions and ideas emerged. Backcoding was routinely performed as new categories emerged. Our coding procedure began at the level of the individual and then looked for interindividual patterns or nonpatterns. The significance of the metaphor of family was suggested by the focused listening to the narratives and conversations of the staff. The metaphor was so pervasive through various parts of the interview that it was commonly presented as something to be heard at each level of analysis.

	Results

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There are two major ways that the concept of family enters into caregiving staff members' discussions of their experiences of resident dying and death. In each there is a strong theme of the metaphor of family. First, staff members describe their feelings toward residents as family-like, with some staff members referring to residents as carrying specific kin-like family roles. Second, staff members spontaneously recall stories of deaths in their own families and describe how meanings of resident deaths and family deaths are interrelated. When staff members spoke in terms of the family metaphor, they generally were referring to relatively long-term residents.

Family-Like Feelings Toward Residents
In both nursing homes, caregiving staff members spontaneously referred to family themes when they described their ties with residents. A CNA spoke of a widow who had no close kin and whose only child, an adult, had died 8 years previously:

There was one lady in particular. She wanted to die. She was alert. She didn't want to suffer any more. But she didn't want to be alone when she was dying. So I took extra time and I came in ... when I wasn't working.... I came in to sit with her. I held her hand.... We prayed together, and very peacefully—that made me feel so good—she peacefully, really peacefully, went. Closed her eyes and ... I was right there when she died. She had her wish. She didn't want to be alone.

In response to a question about the impact of moving a dying resident to another unit, a CNA spoke of the need to maintain proximity with an attachment figure: "You can't move them. It's their home. They got used to the nurses. It's like their second family. And when they lose family at home they still feel like they have family here."

A CNA responded to the question "How openly is death and dying talked about by staff?" by saying,

When we knew that person for so long and she is getting closer to dying, sometime[s], you know, [we] talk to each other and say, "Oh, look at this person. We going to miss her" or something like that. It's like your family. You know we are like family.... So we think about how the person's been here and how we've been with her, and look what she's going through.

When caregiving staff members refer to the family metaphor and suggest that their relationship with a resident is like family, they are clearly not saying that the resident is family. The following statement exemplifies this distinction while maintaining the salience of the image of family in the staff's relationships with residents. Although an RN charge nurse wanted to treat the resident as he would treat his own family member, he said,

I think you definitely have a boundary there. You can only let yourself, you know, because if it was my own family member, how caught up I'd be, I couldn't do that to these people. I mean, I wouldn't be able to function in this job. So there is a boundary.

Staff members mentioned here described the resident as like a generic family member. It is not unusual for staff members, however, to assign specific family-like roles in relation to some residents—particularly the kin positions of parent and grandparent. In our research, staff members tended to see residents as older kin, not as young children.

An LPN said,

I have 50 grandmothers and grandfathers [here]. That's how I look at it.... The way I see it, I wouldn't do anything to this person that I wouldn't want somebody to do to my parents or my grandparents. I think if you keep it personal like that it's a lot easier to realize that everybody laying in a bed is a human being.

In describing her work, an RN said, "My job is to make them comfortable, to make sure they're happy. If there's someone you're fond of ... then it's something that you want to do because you see your parent there."

After a resident's death, some staff members speak of the death as a family-like loss. A CNA indicated that she prefers working in a nursing home to working in a hospital. She sees nursing home work as

more personal; working in a nursing home is like a family. You become a family because the residents live here all the time ... you get to know them ... and then one of them dies, it's like losing a family member. So when they die it can be hard.

Another CNA, in response to being asked if it's okay to cry in front of the family, said, "I think sometimes it's okay, for the simple fact that after they die, because then they know the people was loved, taken care of well, they was going to be missed." The CNA may have felt the tension between her prerogative to cry and the family's primacy in grief. She seems to have rationalized her expression of grief by identifying with the family.

A CNA, in response to our question "When you think about residents dying in the nursing home, what comes to your mind?" said, "What comes to my mind is how we took care of that person for so long and then how we're going to miss that person ... you take it like it's one of your family is passing through." Here the family-like meaning of the tie with residents intensifies a sense of loss when they die.

An LPN care coordinator, when asked about crying by staff members in front of a bereaved family, said, "It's all right just don't get out of hand, cause then see if you see her mother dying, then you're going to be thinking of your mother dying. I'll be bawling for the next hour." In this dense statement, she spontaneously thinks of her own mother's dying at the same that she controls her expression of grief. There seems to be a fusion between the two mothers, rather than a distinction between like family and is family. Even when the staff member does not want to see a resident as family, she cannot help expressing the paradox.

Stories of Deaths in Staff Members' Own Families
In interviewing staff members, we heard many spontaneous references to deaths of their own significant family members. Some staff members stressed that thoughts of family deaths impinged upon them in their work role. Conversely, staff members' thoughts of deaths in the nursing home were seen by them to influence their experience of family deaths.

Deaths in a staff member's family may affect a staff member's response to resident deaths. An LPN said,

My mother's passing made me more compassionate to the residents here. Believe it or not, I see my mother in every one of them.... So I hug and kiss them all. I used to do that with all the residents, and then they passed this rule that said it was abusive to touch the residents, so I stopped hugging them and touching them and calling them sweetheart and honey. Do you know what? They got all upset. "What's the matter? What did we do? Don't you like us anymore?" So I said, the hell with it, I'm going to hug them and kiss them. If I get fired, I get fired. Okay, I even kiss some of the families. I walk up and I [big smacking, kissing sound and laughter].

Intense feelings arose in some interviews when staff members referred to deaths of significant family members. A CNA who had worked in the nursing home for over 2 decades spoke about the impact of the death of Mrs. Cohaen:

CNA: I loved Mrs. Cohaen. I would dress her and put lipstick on her.... She died about 6 months ago.... I was heartbroken.

INTERVIEWER: How did her death affect you personally?

CNA: Well, by me knowing her doing so well and then seeing her fail, you just didn't want to see her like that. I got a little emotional because I [had] just lost a family member.

In some instances, resident deaths may affect staff response to family deaths.The CNA who spoke about the death of Mrs. Cohaen later said that her 21-year-old son had been killed within the year. We later asked her, "How does working here where dying is part of daily life affect other parts of your life?" She replied,

Working around death. I saw my son laying on the sidewalk. I knew he was dead—that was something they didn't have to tell me. I knew it. That was the toughest thing I have ever in my life faced.... The police officer said that statement I made that I worked around death all the time so I knew. It touched him. Now I look at things differently. Life is too short.... It's a blessing if you live to be a ripe old age.

When residents are seen as like family and many deaths occur, staff members may develop a pattern of controlling the impact of the family metaphor. Thus, they would deny their feelings and expression of grief. An RN charge nurse spontaneously said,

My grandfather died 2 weeks ago. It was good. It was in the last stages of Alzheimer's ... and I'm at the funeral home, and I'm looking at myself and ... man, have I become calloused.... I mean, I felt bad for my mother whose father it was, and my grandmother [but] I definitely have a different [way of] handling it than the rest of my family does. But then they're not dealing with this 30 times in the last 2 years.

	Discussion

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Both dying, an intimate process, and death, an ultimate event, are tied in with personal feelings and life experiences of each individual. They are centered in the family experience, and they provide the roots for the family metaphor. Over the life course, for many persons the primary cultural context of dying and death involves close family members. Deaths of old people are generally important to family members who have decades of shared history. They are expected to be the primary grievers. It is not surprising that the subject matter of dying and death reminds staff members of family and of their own family losses.

The family metaphor is rooted in the cultural expectation that family members provide care at the end of life. Staff members, however, carry responsibilities for aspects of the residents' lives that culturally are seen as the province of the family. Hockey (1990) has suggested that in nursing home caregiving "a physical closeness not customarily found outside sexual or familial relationships is permissible" (p. 111). Thus, staff members may see themselves as family surrogates (Chichin, Burack, Olson, & Likourezos, 2000). There is evidence that one of the major reasons that nurse's aides remain on their job is their bond with residents (Monahan & McCarthy, 1992). For that small group of residents who have no kin, or none who are involved in their lives, the staff may take on more family-like responsibilities and concerns, and the family metaphor is strengthened. Staff members may feel that they replace the function of the family (Sidell, Katz, & Komaromy, 2000).

Central themes in family relationships develop in staff–resident ties. We found family themes such as emotional attachment, intimacy, empathy, obligation, and compassion. Compassion has been considered a central ingredient in caregiving for persons who are dying (Byock, 1997; Davies, 1998; Savishinsky, 1991). Grollman (1980) wrote that "compassion consists of doing something loving for someone you do not ordinarily love" (p. 69). This suggests doing something "family-like" for someone who is not "family" (Grollman, 1980). Staff's respect for the value of family bonds and relationships (Chichin et al., 2000; Seale, 1990) is reflected in the family metaphor.

Family Metaphor Thwarts Barriers to Staff Grief
The family metaphor potentially provides the staff member with a mechanism that buffers and counteracts the cultural and institutional factors that thwart staff members' experience and expression of grief. When a staff member sees a dying resident as family-like, there is a tendency to value the life of the resident and the relationship and to minimize the impact of the cultural ethos of ageism. The metaphor of family may help to validate the staff member's loss.

The family metaphor can counteract disenfranchised grief and allow grief to be felt and expressed. Clinical research has found that, in general, bereaved persons tend to create a balance between experiencing loss and grief on one hand and avoiding it on the other hand (Rubin, 1999; Stroebe & Schut, 1999). In the nursing home the family metaphor can help staff members find a balance between controlling grief and expressing grief, between attachment and detachment with dying and deceased residents (Kamerman, 2002). This balance, or wish to find the "right distance" (Parkes, 1986), is in part facilitated by the family metaphor.

The family metaphor acknowledges the importance of the potential or actual loss, and it creates a more permeable boundary between living and dying. When residents are thought of as family-like there is more threat of loss. Thus, staff members may have more concern about the natural trajectory of decline and be less likely to avoid thoughts of dying.

In spite of the institutional value of professional distance, staff members do talk of residents in family-like terms and find satisfaction in expressions of family-like attitudes and behaviors. Recall the LPN who insisted on hugs and kisses with residents, emphasizing the value of emotional labor over professional distance. This emotional labor may create the tendency for staff members to reinforce the psychosocial bonds of caring and concern for residents. The family metaphor enables the staff member to acknowledge the family-like relationship and emotions that are intrinsic to caregiving (Abel, 1995). The lack of the staff's clarity in what is permissible in expressing emotion in front of relatives occurred in this study as well as in research in the United Kingdom (Sidell, Katz, & Komaromy, 1998). The family metaphor counteracts professional distance when it facilitates a staff member's expression of grief, while still allowing for the primacy of family grief.

Residents are often seen as dependent, frail, and powerless. The family metaphor attempts to compensate for the imbalance of power between the caregiving staff and residents. A staff member's position and sense of control is diluted with thoughts of family-like ties. As a result, the family metaphor may enhance the resident's sense of personal control.

Generally, nursing homes minimize rituals at the end of life. The family metaphor may help to legitimize and possibly increase such rituals. In each of the nursing homes we studied, there were opportunities for staff members to attend viewings or memorials. In these situations, staff members were clearly secondary to family. To express their grief, staff members initiated informal and often brief conversations memorializing recently deceased residents. Our observations suggest that this quasi-ritual consists of sharing positive as well as negative characteristics of the deceased resident in a family-like way.

Complexities of the Family Metaphor
Although the power of the family metaphor is strong, and it generally implies that staff members are using family images to reflect their closeness with residents, the family metaphor is also used to set a boundary between the residents and the staff. Staff members recognize that family-like is not the same as family. This may be a protective mechanism for staff members. Clinicians have suggested that caregivers can identify too strongly with the dying resident, family members, or both, and they can become overwhelmed and unable to do their jobs well (Vachon, 1998; Weisman, 1981). We suggest that a balance in the simultaneous presence of family-like feelings and the control of these same feelings is a central process for nursing home staff members as they relate to residents at the end of life.

There are parts of every metaphor that do not and cannot fit the object that the metaphor represents (Lakoff & Johnson, 1980). The family metaphor does not demand a one-to-one correspondence between the personal sense of family and the family-like image of residents. Staff members do not include residents within the boundaries of their own family. There is no blood or legal tie; the staff member rarely if ever has a complex, multilevel lifelong history of connection with the resident; there are no cressive family ties that involve unconditional bonds (Turner, 1970). There is a persistent paradox of seeing the resident as like one's kin and not like one's kin.

Pervasiveness of the Family Metaphor
The family metaphor has emerged in the context of our research that specifically examines end of life, dying, death, and bereavement. It is our impression that this metaphor is pervasive in the nursing home, although it may be heightened as death comes into focus.

Only a handful of staff members did not want to be interviewed, and this occurred particularly if they had a recent death in their family. Some implied that they did not want thoughts of family deaths to intrude into the workplace, and others suggested they feared being overwhelmed by the combination of personal deaths and resident deaths, and the risk of bereavement overload (Kastenbaum, 1969). The power of the family metaphor is reflected in the reasons for their refusals.

Most caregiving staff members in the two nursing homes were African American. African American families often incorporate nonblood relatives into their extended family networks as fictive kin (Smith, 1998). We speculate that such openness to viewing nonkin as family-like may have enhanced the relevance of the metaphor of family. Differences between African American and European American caregivers in their use of the family metaphor are beyond the scope of this article.

The two nursing homes that are the focus here differ in their cultural backgrounds, their ethnic and religious roots, and their religious rituals and practices, yet we have found that the family metaphor is equally pervasive in each home. In our continuing research in eight additional not-for-profit and for-profit nursing homes and assisted living facilities, the family metaphor has continued to have salience for caregiving staff members. Further, a national survey of administrators in 400 U.S. nursing homes about the terminal care they provide for residents with dementia indicated that their best practice, second only to keeping the resident comfortable, was "staff treats resident like family" (M. S. Moss et al., 2002, p. 241). Extensive research in the United Kingdom that focuses on end of life in nursing homes has found congruent patterns (Sidell et al., 1998).

In summary, when nursing home staff members experience death and bereavement, they have both self-oriented feelings (e.g., loss of the person) and work-oriented feelings (e.g., loss of the caregiving tie; Papadatou, 2000). Thus, the metaphor is a "transforming bridge" (Becker, 1997, p. 60) between the personal experience and the work experience of nursing home staff members.

We have found that as caregiving staff members talk about dying and death of nursing home residents, they often describe their thoughts, experiences, and behaviors metaphorically. The role of the metaphor of family has emerged strongly and consistently. Confronted by resident deaths, staff members spontaneously refer to their own personal histories to help them construct the meaning of their experience. The metaphor of family helps us to understand how staff members manage their grief in the nursing home. The salience of the family metaphor tends to legitimize the feelings of loss that staff members have in reacting to resident deaths. This metaphor can be seen as a counterweight to the cultural and institutional milieu that tends to pay little attention to the impact of resident deaths on the work world and personal world of staff members. The metaphor of family provides a frame through which we can view and better understand the complex role of hands-on caregivers as they relate to residents and as they cope with dying and death in long-term care.

	Acknowledgments

 
This research was supported by the National Institute on Aging under Grant AG13993.

	Footnotes

 
Decision Editor: Charles F. Longino, Jr., PhD

Received for publication August 1, 2002. Accepted for publication March 27, 2003.

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