Eleanor Feldman Barbera, Ph.D.

I started working in long-term care when I was in my early 30s and I was shocked at first when the residents died. I was used to falling in love with my patients — I consider it a prerequisite for psychotherapy. I wasn’t used to them dying on me. 

In the years since, I’ve lost many, many people who have touched my heart, but I can still remember very clearly the ones who passed when I was new. In order to make it in LTC, I’ve protected myself by falling in love in a different way. 

A recent New York Times article, “Is Giving The Secret of Getting Ahead?”, piqued my interest when it touched on the impact of death anxiety at work, suggesting that it could have an effect on absenteeism and turnover. Working with residents in LTC is all about coping with death, and facilities have huge problems with absenteeism and turnover —surely there was a connection. I raced through the article, located the research paper it mentioned, “The Hot and Cool of Death Awareness at Work,” and plowed through that too. What I read seemed very applicable to long-term care, so I’m going to present the gist of the research and ways to reduce absenteeism and turnover based on these ideas.

Mortality cues

In “The Hot and Cool of Death Awareness at Work,” authors Grant and Wade-Benzoni outline different types of work where mortality cues can be chronic or acute, internal or external to the job, and personal or vicarious. A firefighter, for example, is constantly in a work situation that threatens his life. This would be considered a chronic, internal, personal mortality cue. A nursing home employee would have a chronic, internal, vicarious mortality cue because they are repeatedly exposed to other people at work who are dealing with end-of-life issues. 

Reactions to mortality cues

The authors state that there are two different reactions to being aware of death at work. A “hot” reaction leads to self-protection and “stress-related withdrawal behaviors” such as absenteeism, tardiness, and turnover. A “cool” reaction leads to prosocial behaviors such as helping, mentoring, and thinking of work in the context of contributing to society.  They refer to the hot reaction as “death anxiety” and the cool reaction as “death reflection” and note that chronic exposure to mortality cues can shift a worker from death anxiety to death reflection. 

This shift from death anxiety to death reflection describes my experience as I continued in long-term care. It also explains why some new workers bail out early and others persevere to become beacons of light in a challenging environment. In addition, the researchers propose that as we age, we become more likely to experience death reflection rather than anxiety. Younger workers, therefore, are more likely to withdraw from the nursing home environment.

Retaining new young workers

So how do we retain the new young employees in whom we’ve invested time and resources for training? The answer can depend on whether the worker thinks of his or her employment as a job, a career or a calling.  If long-term care is considered just a job and a means to the end of supporting a family, the worker is more likely to express prosocial behavior outside of work. Those who view their employment as a career with importance in life or as a calling that gives meaning to their lives are more likely to show their prosocial behavior at work. Employees who think of their job as just a job will be more motivated by monetary rewards, whereas career and calling employees will be more motivated for opportunities to give back within their jobs.


The research suggests that some of the reason we’re losing workers early in their employment is because we’re not acknowledging their death anxiety. Based on this theory, we should:

  • Address the issue of death during the training and orientation period so that new workers know what to expect and that it’s okay to talk about the impact of being around ill and dying people.
  • Provide senior staff mentors with whom new employees can discuss their reactions to losses. This allows new workers to address concerns and provides experienced workers with a prosocial outlet.
  • Offer resources for workers to cope with grief such as employee assistance programs, chaplaincy services, or staff training. Losses at work can often trigger past losses from one’s personal life.
  • Consider offering a bonus or salary increase for workers who have stayed on the job a certain period of time. This can motivate job-oriented employees and help them reach the point of having enough exposure to mortality cues to move from death anxiety to death reflection.
  • Provide monetary rewards for taking initiative and for mentoring as another means of motivating those employees with a job orientation.
  • Emphasize that long-term care is a community within itself and that contributions within this environment are contributions to the world. This is reflected in the story of a hospital porter who was asked what he did at the facility. He replied, “We save lives here.” Everyone in long-term care has the opportunity to contribute to the betterment of the world, no matter what his or her role.

Eleanor Feldman Barbera, PhD, the author of The Savvy Resident’s Guide, is an accomplished speaker and consultant with over 16 years of experience as a psychologist in long-term care. A long-time contributor to McKnight’s publications, this blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.