HJNO Mar/Apr 2026

18 MAR / APR 2026 I  HEALTHCARE JOURNAL OF NEW ORLEANS   systems. First, caregivers must be recognized as participants in care, not obstacles to it. Care- givers hold essential relational, historical, and practical knowledge about the person receiving care. They regulate environments, notice subtle changes, and provide conti- nuity that no rotating system can replicate. Treating caregivers as visitors, subject to removal or exclusion, reflects a misunder- standing of their function and undermines patient safety. Research on care transitions and direct care work consistently demon- strates that inclusion of caregivers improves outcomes while exclusion increases dis- tress, grief, and moral injury. Participation must be presumed, not negotiated under duress. Second, anticipatory grief must be named, normalized, and legitimized. Grief that begins at diagnosis is not pathologi- cal; it is predictable. Caregivers experience cumulative loss across illness trajectories, role reversals, and relational ruptures long before death occurs. Yet healthcare and workplace systems rarely acknowledge this reality, leaving caregivers to absorb grief silently while continuing to perform. Normalizing anticipatory grief allows care- givers to seek support without shame and prevents the mislabeling of deferred grief as dysfunction later on. Third, healthcare workers must be trained in caregiver inclusion and grief literacy. Most clinicians receive extensive training in symptommanagement and risk mitigation, but little preparation for navigating attach- ment dynamics or caregiver distress. As a result, caregiver emotion is often misread as interference rather than information. Training that emphasizes relational safety, attachment awareness, and ethical inclu- sion would reduce unnecessary harm and improve trust. Studies of direct care work- ers show that institutional recognition and support significantly reduce grief-related distress and burnout. The same principles apply to family caregivers, who are often afforded even less structural support. Finally, healthcare systems must shift from rigid policy compliance toward rela- tional care ethics. Policies designed for efficiency and liability management can- not account for the complexity of human attachment. When applied without discern- ment, they produce preventable harm. Rela- tional care ethics recognizes that safety is not only procedural, but emotional and rela- tional. It asks not only whether a policy is followed, but whether dignity is preserved and harm minimized. This shift does not require abandoning structure; it requires applying it with humanity. Responsibility for this shift does not rest with caregivers themselves. It rests with healthcare institutions, administrators, poli- cymakers, and training programs that shape the conditions under which care occurs. Without explicit institutional commitment, through policy design, staff education, and leadership accountability, caregiver inclu- sion and recognition remain discretionary rather than guaranteed. Caregivers should not have to prove their worth in moments of crisis. They should not have to suppress grief to remain included. They should not have to endure trauma in silence to keep others safe. Recognizing caregiver grief — before death, during care, and after loss — is not an act of kindness alone. It is an ethical imperative. When caregivers are protected, patients are safer. When grief is witnessed, it becomes survivable. When systems honor relational truth, healing and sustainability become possible for all involved. n REFERENCES J. Bowlby, A Secure Base: Parent-Child Attachment and Healthy Human Development (Basic Books, 1988). J. Bowlby, “Attachment,” in Attachment and Loss, vol. 1, 2nd ed., ed. J. Bowlby (Basic Books, 1982). J. Bowlby, “Separation: Anxiety and Anger,” in Attachment and Loss, vol. 2, ed. J. Bowlby (Basic Books, 1973). J. Cassidy and P. R. Shaver, eds., Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd ed. (Guilford Press, 2008). D. G. Dutton and S. Painter, “Emotional Attachments in Abusive Relationships: A Test of Traumatic Bonding Theory,” Violence and Victims 8, no. 2 (1993): 105–20. C. R. Figley, ed., Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized (Routledge/ Taylor & Francis, 1995). J. A. Gray and J. Kim, “Direct Care Workers’ Experiences of Grief and Needs for Support,” Journal of Applied Research in Intellectual Disabilities 30, no. 6 (2017): 995–1006. J. Groopman, “The Grief Industry,” The New Yorker, January, 19, 2004, 26, 30–38. A. Hansen, et al., “Bullying at Work, Health Outcomes, and Physiological Stress Response,” Journal of Psychosomatic Research 60, no. 1 (2006): 63–72, https://doi.org/10.1016/j. jpsychores.2005.06.078. M. Heilig, et al., “Addiction as a Brain Disease Revised: Why It Still Matters, and the Need for Consilience,” Neuropsychopharmacology 46 (2021): 1715–23, https://doi.org/10.1038/s41386- 020-00950-y. M. R. Holmes, et al., “Impact of the COVID-19 Pandemic on Posttraumatic Stress, Grief, Burnout, and Secondary Trauma of Social Workers in the United States,” Clinical Social Work Journal 49, no. 4 (2021): 495–504. J. MacKillop, “Is Addiction Really a Chronic Relapsing Disorder?” Alcoholism: Clinical and Experimental Research 44, no. 1 (2020): 41–43. M. Mikulincer and P. R. Shaver, “Attachment, Anger, and Aggression,” in Human Aggression and Violence, eds. P. R. Shaver and M. Mikulincer, (American Psychological Association, 2011), 241–57. Z. Owrutsky, “Sarcomatoid Renal Cell Carcinoma: 7 Facts About a Rare but Aggressive Cancer,” MyKidneyCancerTeam, June 12, 2025, https:// www.mykidneycancerteam.com/resources/ sarcomatoid-renal-cell-carcinoma-facts-about- a-rare-but-aggressive-cancer. V. R. Pine, “Grief Work and Dirty Work: The Aftermath of an Aircrash,” OMEGA Journal of Death and Dying 5, no. 4 (1975): 281–6. P. R. Shaver and M. Mikulincer, Attachment in Adulthood: Structure, Dynamics, and Change, 2nd ed. (Guilford Press, 2013). B. A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (Viking, 2014). D. M. Wilson, et al., “The Potential Impact of Bereavement Grief on Workers, Work, Careers, and the Workplace,” Social Work in Health Care 59, no. 6 (2020): 335–50. S. P. Wladkowski, et al., “Grief and Loss During Care Transitions: Experiences of Direct Care Workers,” OMEGA Journal of Death and Dying 87, no. 4 (2023): 1308–22. CAREGIVER GRIEF