Practices following the death of a loved one reported by adults from 14 countries or cultural/ethnic group.

Aims: The purpose of this study was to examine the reported ritual practices (dealing with the deceased's remains, wake, funeral, burial and celebration) of White non-Hispanic, Black non-Hispanic and Hispanic/Latino adults in their country of origin or ethnic or cultural group in the United States following the death of a loved one. Design: This descriptive study is a secondary analysis from a longitudinal mixed-methods study that examined parents' health and functioning following the death of a child.
Methods: Adult parents whose child died in neonatal intensive care units or paediatric intensive care units were recruited from four hospitals and from death records. Data were collected from 61 adult parents at 7 and 13 months postinfant/child death using semi-structured interviews about the child's death. Only those parents who responded to questions about usual death practices in their country of origin or cultural group were included in the data analysis.
Results: Thirty-two adults from 14 countries reported practices in their country or cultural group after a loved one's death including keeping the front door closed, walking funeral processions with a band playing, the deceased in a car accompanied by family and friends, fireworks, making home altars for deceased spirits with food and water for adults, toys and candy for children and no TV or radio for sometime. Relevance to clinical practice: For community health nurses, understanding these practices is important in being sensitive and appropriate around the death. Asking the family about specific practices they hope to carry out and noting this in the family's record will help alert providers to the family's wishes at this challenging time.

INTRODUCTION

Death of a loved one is a painful experience for most people. After a death, those with common bonds, such as religion or ethnic origin, perform rituals to recognize the death and honour the deceased and the family. Rituals can legitimize grief, provide an arena where the death is acknowledged and its finality is accepted, create a safe place for mourners to express emotion, maintain a connection with other family and friends and with the deceased and help the bereaved to continue their own functioning (Baloyi, 2014; Gudmundsdottir & Chesla, 2006). Ritual practices after the death of a loved one include dealing with the deceased's remains, holding wakes, funerals, burials and gathering celebrations that can differ across cultures, religions, race and ethnicity, socio‐economic group and ages of the deceased (Reeves, 2011). Attending these death events is often seen as a family obligation (Baloyi, 2014; Schoulte, 2011). Family members unable to attend often experience feelings of loneliness and isolation (Contro et al., 2010). Knowledge of these ritual practices is important for community health nurses in providing support that is sensitive and appropriate for the remaining immediate family members and friends.

BACKGROUND

For most families accepting that a loved one's death is approaching is difficult no matter the culture, ethnicity or religion. Even when there is no hope of living, Hispanics and African Americans have difficulties accepting a Do Not Resuscitate (DNR) or Allow Natural Death (AND) option, deciding to end a loved one's life or donate the loved one's organs (Bullock, 2011; Lobar et al., 2006; Youngblut & Brooten, 2012). Hispanic Americans and African Americans usually consult with other family members before these important decisions are made (Schoulte, 2011). After the death, wakes, funerals, burials and gathering celebrations occur. While there are recurring practices from the wakes or viewings to the burial or cremation and postdeath gatherings, ritual practices vary within and between racial/ethnic groups and are influenced by religion and socio‐economic status.

Latinos are mainly Catholic (Clements et al., 2003). McGoldrick et al. (2004) suggest that Latinos prefer death to occur at home surrounded by family and friends with care for the dying done by women in the family. Their formal mourning has an open casket where the rosary is recited during the service. The mourners pay their respects to the deceased by wearing black or dark colours. Group prayers are done for the soul of the deceased before the funeral service by family members and friends. A funeral mass is usually done at the church followed by a procession to the graveside service where a priest or deacon blesses the grave with holy water before the burial (Diaz‐Cabello, 2004). Latino rituals include novenas for 9 days (praying the rosary each day after the burial), a mass for the deceased on the deceased's birthday and 1 year after the death and lighting of candles (Clements et al., 2003; Doran & Hansen, 2006). The period of mourning for older Latinos may last for years. Some from Puerto Rico view the afterlife as a spirit world where spirits evolve until they reach moral perfection and are detached from the earth. Their role is to care for the living (McGoldrick et al., 2004). Mexican families report maintaining an ongoing relationship with the deceased in dreams, storytelling and building home altars. The altars for children sometimes include pictures of the deceased, keepsakes and dressing of dolls in the deceased child's clothing, to entice deceased spirits to return home (Doran & Hansen, 2006). Familismo, importance of the family, is stressed and expected.

African Americans gather for prayer and meditation to help the dead transition to the afterlife and to the spirit world (Baloyi, 2014). Death is viewed as transitioning to a new type of life. Easing the transition is dependent on the family preparing food, chanting, singing and praying to ancestral spirits for the entrance of the dead into the spirit world. In African American communities in the United States, the wake is the first occasion when comfort and assistance are given to the bereaved families (Holloway, 2002). Open caskets are usual. The amount of food and the attention given to its preparation were important in past decades and seen as signs of respect for the bereaved family. Bringing prepared food from the store was frowned on by the African American culture. Fried chicken has been a staple during these occasions with a bucket from a food store chain replacing older traditions for younger generations (Holloway, 2002). The tradition of providing meals to the grieving family starts with the wake and concludes with a formal meal after the funeral service. Attending the funeral is a uniting factor, an obligation and in African tradition, not attending may bring misfortune (Baloyi, 2014).

In keeping with African American beliefs, a soul will not go to heaven if the body is cremated (Lobar et al., 2006). The traditions of West Africa, the mourning and dancing, remain strong in Black America in the jazz funerals of New Orleans with the performance of music from legendary brass bands (Holloway, 2002). Kongolese slaves brought to Louisiana would express the soul's sorrow with customary weeping and wailing before they accompanied the dead with much jubilation to the burial sites. The mourners sing beat the drum and dance the deceased's soul to its new home. Elaborate funerals still demonstrate the importance and worth of the deceased in the African American communities (Hope, 2010). In Jamaica, African and European religions and traditions have blended. There, funerals are often held 2–3 weeks after the death to provide time for preparations and family to arrive from afar (Paul, 2007). At the funerals, free expressions of “falling out,” dizziness, fainting and wailing are allowed and often encouraged to demonstrate closeness to the deceased. In contrast, such emotional expressions by whites at funerals are viewed as disruptive (McIlwain, 2001).

In Jamaica, funeral rituals vary and depend largely on socio‐economic status, religious affiliation and rural versus urban residence (Paul, 2007; Marshall & Sutherland, 2008). Before the use of mortuary services, family members maintained the corpse in the home for 3 days and prepared it for burial. Ice was used to slow deterioration, cotton plugged the nostrils and a weight on the abdomen prevented swelling (Burrell, 1996). Well‐attended and elaborate funerals symbolize a life well lived. Plush coffins, lavish clothing for the attendees and for the deceased are important and signify status (Hope, 2010). The funeral service is usually conducted in churches. Hope (2010) comments that two beliefs shape funeral practices: individuals constitute body, soul/spirit and duppy or shadow, and death marks the end of the physical body beginning the journey of the soul/spirit to rejoin the Supreme Creator and other spirits. Wandering of the duppy (shadow) can harm the living and requires rituals to put the duppy to rest. While family plots are still used in some rural areas in Jamaica, a custom from West Africa, burials generally take place in cemeteries (Burrell, 1996). The “nine night” after the death marks the completion of the spirit to the spirit world. The large celebration that follows includes much food, alcohol, music by DJs and dancing.

When children have died, practices may differ based on each culture's beliefs about where children come from before they are born and where they go after they die. However, the research on ritual practices after death of an infant or child is very limited. In many cultures, children are considered pure and innocent and their untimely death guarantees them heavenly status (Brooten et al., 2016). Puerto Ricans dress their children in white, paint the face to resemble an angel and place flowers outside and inside the coffin (Parkes et al., 1997). Some Latinos believe that the novena done for adults after their death are not needed for infants because they are innocent angels and there is nothing to be forgiven (Brooten et al., 2016; Parry & Shen Ryan, 1995). Therefore, deceased infants are dressed in white as a symbol of their religious purity and innocence. There is no specific funeral service for miscarriage, but a funeral service can be arranged by a priest to decrease the parent's distress. In some cultures, infants are buried exclusively in reserved parts of the cemetery or, as in Japan, may have their own cemeteries and family members may or may not be expected to visit the grave thereafter (Parkes et al., 1997). The family members dress in white clothing or wear white head bands.

The purpose of this study was to examine the reported ritual practices (dealing with the deceased's remains, wake, funeral, burial and celebration) of White non‐Hispanic, Black non‐Hispanic and Hispanic/Latino adults in their country of origin or ethnic or cultural group following the death of a loved one.

METHODS

Design and sample

This descriptive study is a secondary analysis from a longitudinal mixed‐methods study that examined parents' health and functioning following the death of a child (Youngblut & Brooten, 2006–2012). Adult parents (White, Black, Hispanic/Latino) whose child died in neonatal intensive care units (NICUs) or paediatric intensive care units (PICUs) were recruited from four hospitals and from death records from the State's Department of Health's Office of Vital Statistics. Data for this secondary analysis were collected from 61 adult parents at seven and 13 months postinfant/child death using semi‐structured interviews.

Families were identified by clinician co‐investigators at each study site. A letter was sent to each family (in Spanish and English) describing the study. Three bilingual health professional students called the families, screened for inclusion and exclusion criteria, described the study in Spanish or English, answered their questions, obtained verbal consent and scheduled the first data collection visit where written consent was obtained. Inclusion criteria are as follows: adult parents able to understand spoken English or Spanish, had a singleton pregnancy, a neonate who lived for more than 2 hr in the NICU or a deceased child (18 years or younger) who lived at least 2 hr in the PICU. Exclusion criteria are as follows: a multiple gestation pregnancy with a deceased newborn, child living in a foster home before hospitalization and death of a spouse in the illness/injury event (e.g. car crash).

Sixty‐one parents (44 English speaking, 17 Spanish speaking) of 47 deceased children participated in semi‐structured interviews about the child's death. For this study, only those parents who responded to questions about death practices in their country of origin or cultural group were included in the data analysis. All 30 participating parents now lived in the United States. Adult parents' mean age was 35 years (SD 9.01); 33% were Black, 27% White and 40% Hispanic; most were married (65%), 49% had incomes above $25,000, 33% had some college or technical school, and 36% were college graduates. Parents identified their native country or cultural/ethnic group as Jamaican (2); Haitian (2); Cuban (2); Puerto Rican (5); Dominican Republican (1); Bahamian (3); Mexican (2); Nicaraguan (1); El Salvadorian (1); Honduran (2); Ecuadorian (2); Chilean (2); Peruvian (2); and Colombian (3).

Measures

At the seven‐ and 13‐month interviews, parents were asked whether the practices they experienced around the death of a loved one in the United States were the same as those regularly practised for deceased loved ones in their country of origin or cultural/ethnic group. Interviews using a standardized protocol with core questions and probes were based on the study purpose, the literature, our own clinical expertise and discussion with two study consultants with expertise in qualitative research and interviewing. Interviews were conducted at a time convenient for the parent(s), in their homes, took one and one half to 2 hr and were audio‐recorded and transcribed verbatim in the language of the interview. Parents were interviewed separately and out of hearing range of each other.

Analysis

Transcripts were compared with audio recordings for transcription accuracy by English‐ and Spanish‐speaking PhD and master's students in health disciplines and any discrepancies resolved by the research team. Content that included discussion of rituals practised for deceased loved ones in their country of origin or cultural/ethnic group including dealing with the loved ones' remains, wakes, funerals, burials and celebration practices postdeath was then abstracted and presented in table format. The Equator checklist that was used contained all of the consolidated criteria for reporting qualitative research (Appendix S1).

RESULTS

Practices dealing with the remains of the deceased, wakes, funerals, burials and celebrations after the death of a loved one varied by country of origin, cultural/ethnic group, religion and age of the deceased (Table 1). In the Caribbean, wakes or viewings were done in the home, funeral homes or church, usually with an open casket. The funeral is attended by family and friends with older persons wearing black while younger ones wear a lighter appropriate colour. Adults from Haiti reported coming down the street with the body in a car, accompanied by family and friends and a band playing. A mass or service is usually at the church followed by a processional to the burial site where prayers and singing are common. A gathering of family and friends is held at the family home after the burial with food, drink, songs, talking and games of cards and dominoes. Family and friends bring food to the bereaved family sometimes for a week. For some families, there is no TV or radio for a period and black may be worn for 6 months to 1 year after the death. Novenas (rosary prayers for 9 days) are done for the deceased's soul to be at peace. In the Dominican Republic, the front door is closed until the ninth day after the death. Recognition of the deceased is commonly held on the one‐year anniversary of the death. Burial is usual, and cremation is not.

TABLE 1

Adults' reports of rituals practised in their native countries

	Wake	Funeral/Burial	After the burial
Caribbean
Jamaica	– Viewing is done on the same day of the death – Viewing takes place at church – Gathering will take place the night before the funeral with neighbours and friends and in remembrance of the deceased	– Family members attend. Singing, reading letters, and life stories – People dress in colours (many in black or white) and celebrate that the deceased is going to a better place. No cremation.	– Play dominoes, drink, and talk – Songs are sung nine nights (night is spent singing and cooking)
Haiti	Person stays in morgue 1 week – Viewing is held – Casket left open – Service at church depends on the age of the deceased – Black and white clothing are worn – Celebrate the life with a party	Come down the street with the body in the car and band plays. Everyone walks down with car – No pregnant women or children at the funeral – Mother who loses a child does not go to the funeral or cemetery – If child dies, black does not have to be worn No cremation	– People come to the house and bring food and drink and spend time with the bereaved family members – Black is worn from 6 months to 1 year after the death of a loved one – Anointing the deceased's head
Cuba	The dead are viewed in the home or in funeral homes Adult family members make all arrangements	A mass is done at church Prayers during the burial – No specific colour of clothing is worn (appropriate colours)	Family visits the dead in the cemetery – Candles are lit in recognition of the deceased (i.e. birthday, 1 year anniversary). Flowers are placed to commemorate the dead – Some families mourn by not turning on the radio, TV, wear black clothing for 1 year
Puerto Rico	– Wake is usually for the family and is all night – Open casket and viewing is done for 2 days – Speak to deceased. Write a letter and place in casket – If a baby death, family view baby before everyone arrives then casket is closed – For other families, if baby death, no viewing only a mass then to the cemetery	– Funeral does not need to be planned so quickly. The deceased is usually taken to church for a service before being taken to the cemetery – Older people wear black, but the younger usually do not believe in wearing black – Prayers and songs while in cemetery	– Close family members and friends go to the home of the bereaved and spend some time there – After someone dies, you do novena (pray for 9 days). The novena is done for the person's soul to be at peace – Family and friends help with cleaning of home and bring food – Food is brought over all week to the home
Dominican Republic	– Viewing usually done in the home	– Everyone is buried – Everyone dresses in black (no red or happy colours)	– Front door of the house is closed until the 9th day when front door is opened—9 days of prayer after burial (1 hr of praying per day) – An altar is placed with a picture and candles, as well as flowers and saints, and this is where people pray every day until the 9th day‐refreshments are served – I year anniversary (a holy hour of prayer is done and family does the rosary). Everybody gets together and goes to the cemetery and goes to mass – No TVs or radios are turned on – People visit the grieving family after the loss for a long period of time
BAHAMAS	– Wake is done until the next morning of the burial	– People dress in black – A lot of people attend the funerals	– People eat and are sociable
North America
Mexico	Deceased infants are baptized – The rosary is not done for infants because they are free from sin – A wake is done for the entire night, and the family talks all night – Wake is usually done in the home, and the candles that the 4 priests carry are rented – The rosary is done – Family members and closest friends attend the wake For deceased adults, people dress in black – A wake is usually not performed for infants because they have no sins – Deceased infants are dressed in baptism clothes during the wake – For infants, white flowers and candles are used – For children, dress in white since children are believed to be angels	Family members purchase place of burial for person Burial day after wake – Veladoras (candles) are placed in person's 4 corners – Family members and friends are present – Mass is done at the burial, and fireworks are lit to say goodbye – People dress in black for deceased adults and in light colours for deceased infants – Deceased infants are buried not cremated – Catholics do not believe in cremation	Rosary for 9 days (novenas)—during this time is the lifting of the cross, psalm sung/prayed, cross lifted and placed in cardboard boxes and placed in pantheon. People bring food, flowers and candles – Pantheon's made of dirt and cement. Altar is made Offerings are made: Candy is placed for child and food is placed for adults. Water, salt and food are placed for an older person
Central America
Honduras	– A bow is placed on the front and back door of the home so people know that the family is mourning – Wake is done in the home all night until the morning Prayers are done in the home – If person dies in the hospital, he is taken in a coffin to the house and placed on a table. Ice is placed under the table to keep the body fresh. Flowers, candles are placed around the body to make it pretty. An altar is prepared. People stay with the body for 24 hr then go to the cemetery – Food, coffee is served at the wake. People play cards, dominoes within the first 24 hr Evangelist—when someone dies there is no more praying. They only pray for the ones living because the family members are the ones that need God to give them strength (no 9 day prayer) – Family members help with all the arrangements so the closest family could be with the deceased	– Person is buried within 3 days – Family members dig the hole and can decorate it with a tree, flowers or fence – Cars and people move to the side when there is a funeral procession out of respect to the dead and the family – Mother dresses in black, everyone else dresses normal	After the death, Catholics meet at 3p−4p for 9 days to pray for the body – Believe God takes care of everyone, those who do well in life are taken care of by God – People give you their condolences
Nicaragua	– People are supposed to pray – If an infant dies, people do not have to pray and no masses or novenas are done because the infant is an angel and has no sins	– Funeral is done in the home – People wear black
El Salvador		– Dirt is thrown on the coffin – People dress in black	– Nine night is done. Food is cooked and people stay up the whole night playing dominoes and drinking till daylight
South America
Chile	– Body or ashes exposed in the home for 1 day – After death but before the burial family sits around and talks and shares stories to support each other. Everyone comes at night to talk and eat. Friends, family members, and neighbours spend all night	– Burial is within 1 day Cemetery procession either by car or foot – Place ashes in family niche where other family members are buried – People dress in black or white or dark clothes	Family supports each other – Family is invited to spend weekends together – No loud noises, watch TV with very low volume, no music – Take ashes to church and have priest ordain mass
Peru	– Evangelist do not pray for the dead; they only pray for the living (family members so that God can give them strength) – Family members help with all the arrangements so that the immediate family could be with the deceased – Wake in the family home, funeral home or special place (club) for military, teachers, etc. – People are given cookies, coffee and a typical liquor Everyone wears black, and it is customary to wear glasses – People send wreaths – The dead have a lot of flowers all kinds (roses, tulips). Special bouquets are made for children	– According to law, the person needs to be buried within 3 days after their death – Funeral is held the day after the wake – Mass held at church or funeral home. Mass with the body present – Funeral procession is done – In some regions, it is customary to carry the coffin on shoulders to all of the places where the person had lived, and finally, to the cemetery. People pray and sing through the streets – All of the family attend the burial – No one leaves until the body is buried	– Family members congregate at the house and may stay as long as 1 week to provide support to the family – Mass is held 7 days, 1 month and 1 year after the death. Meal is offered. Keepsakes such as rosaries, crosses and religious images are given out
Colombia	– When people die they can be in the home for up to 7 days. During this time, prayers are said and blessings occur 24 hr/day, 7 days/wk (prayers for the soul of the person) – People sit and gather at the wake until the mass is done – Attendees dress in black	– Mass at the funeral home – Funerals are usually done with open casket – Family attends burial – Cremation	– Mass 1 month after the burial – Yearly mass done for the deceased – Novena or mass not done for children since they are angels – Santos Oleos (holy oil) is used on the deceased for purification. It is believed that once the deceased is purified with holy oil, then they can enter into the spirit world. Santos Oleos not done for children, only for adults since children are angels
Ecuador	– Open casket is customary and people can stay as long as they want	– Crying seen more in funerals in Ecuador compared to the United States

In Mexico, many of the ritual practices reported were like those conducted in the Caribbean. The wake is usually done in the home. People dress in black, and younger persons in other colours. Burial is used, not cremation and fireworks are lit to say goodbye to the deceased. The novena (9 days of prayer) is done with each day making mention of Jesus' sacrifices on the cross (lifting of the cross). Altars are made in the belief the deceased spirit visits the altar. For adults, food and water are placed on the altar, toys and candy for children.

Practices reported by adult parents from Central America have many of the same activities. The wake is done in the home. In Honduras, if the death occurred in the hospital, the deceased is taken to the family home in a coffin and placed on a table for the wake. Ice is placed under the table to keep the body fresh for the viewing. The burial is within 3 days and family members dig the grave. Black is worn commonly. The “nine‐night” prayers (novenas) are done.

Many of the same death rituals are conducted in South America according to the adult responses. In Chile, the body or ashes are in the home for 1 day then buried. There is a procession by car or on foot to the cemetery. In Peru, by law, the deceased must be buried within 3 days of the death. The wake is held in the family home, funeral home or special place known as a club for special groups such as teachers and military. In some regions, it is customary to shoulder the coffin and walk to all the places the deceased had lived as one last visit, then to the cemetery. In Colombia, the deceased may be in the house up to 7 days and prayers are offered 24 hr per day for the 7 days. Mass is at a funeral home, open casket, then burial or cremation. A one‐month mass is held after the burial.

Overall, ritual practices for child deaths differ from those conducted for adults. For deceased children, a mass or service is shorter or eliminated and prayers are fewer or eliminated since deceased children are viewed as without sin and are now angels in heaven. Black clothing is not worn for children's services in favour of lighter colours.

DISCUSSION

McIlwain (2001) comparing death rituals of Blacks and Whites found few differences in their rituals but found statistically significant differences in the emotional expressions of persons attending the wakes and funerals. Blacks demonstrated more outward emotional expressions including weeping, wailing, falling out and dizziness. Black pastors were accustomed to these expressions and stated that they ‘let the family handle it.’

In the wakes and funerals of Whites, such emotional expressions were viewed as disruptive and White pastors routinely took persons with these behaviours to a private room to calm down. These differences can also be found in East Asian countries where weeping and wailing of bereaved family members are expected and encouraged. For the Chinese, not showing grief or not enough grief is perceived as being unfilial and opens the person to gossip and back‐biting (Kim, 2015). Gamliel (2017) conducted 28 interviews with 18 female and 10 male Yemenite‐Jewish wailers and concluded that wailing brings forth compassion and understanding with those that take part in this tradition and fosters mutual support among community members. At times, wailing enables the mourner to momentarily bond with the deceased (Gamliel, 2014).

The Japanese, however, hardly cry out at funerals. A Buddhist priest explained that if you drop your tears on the dead, the dead river will be flooded, and the deceased cannot go to the other world. If the deceased spirit wanders this world, the wandering ghost may cause harm to the living (Kim, 2015). This belief is like that of the duppy in the Caribbean who may cause harm to the living if not appeased.

Practices may also differ by the religion of the deceased and the deceased's family. In heavily Catholic countries, cremation is not allowed, as our study participants commented, novenas are done commonly and the lighting and carrying of candles is common. However, Glass and Samuel (2011) found that the use of cremation is becoming more common due to cost and land use. In their study, they also found that reasons to reject cremation included absence of closure and lack of a sense of place. Participants in our study indicated that burial was preferred but cremation was also an option in Colombia.

Practices differ by age or generation of the mourner. Study participants indicated that adults usually wear black to the death events; however, persons often wear lighter colours and “regular clothes,” a change Wouters (2002) indicated is becoming more common. Older adults may carry out traditional practices while the reasons for the practice may have long been forgotten. One such practice may be the throwing of soil into the grave by hand as mentioned by study participants. In African traditions, men dug the grave and covered it after the funeral using shovels. Women did not participate in these activities and did not use shovels, thus throwing handfuls of dirt into the grave allowed women to participate. While this practice continues in some countries, today people generally throw flowers instead (Baloyi, 2014). Younger generations also have undertakers prepare the loved one's body for the viewing. In the African American and Afro‐Caribbean cultures, the family often carries out these activities which are important death rituals. Family members (usually same sex) wash the body, groom the hair and dress the dead loved one. During the viewing, laying‐on of hands, touching, kissing and conveying one's grief are usual and encouraged (Baloyi, 2014).

In Haiti, Catholic and West African‐based burial rituals are conducted together (Huggins & Hinkson, 2019). A Christian priest and a Vodou priest conduct the ceremony. In the remote villages, day‐long celebrations take place with individuals singing and dancing. After the funeral celebration, pigs, cows and goats are slaughtered for the meal. The family then organizes a West African tradition called “nine‐night” celebration. Food is prepared, and visits from the villagers are customary. Praying is done every night, and it is believed that the soul will depart to its destination on the ninth night. Our study findings are similar, with study participants sharing common celebrations after the death including music, singing, food and gatherings, as well as a novena or a rosary prayer for 9 days seen in the Catholic religion and in the West African tradition called “nine‐night” celebration. Even though 98% of Haitians are Catholic, they also believe in Vodou, a West African religion (Huggins & Hinkson, 2019).

Study participants noted that practices conducted for children differ from those conducted for adults. Services were reported to be shorter with fewer prayers, fewer family and friends attending and fewer family gatherings after burials. Cremation may be used, and findings were consistent with the research of Cacciatore and Ong (2011–2012). Our study findings were somewhat different from Asian death rituals. In a study conducted by Tseng et al. (2018), 16 Taiwanese women who experienced loss of their infant due to stillbirth were interviewed about the significance of death rituals for them and their families. In the Taiwan culture, speaking about death is a taboo. Parents who have suffered a stillbirth are unable to speak openly about the event, and public mourning and burial ceremonies are non‐existent in this society. A few of the ritual activities that mothers participated in were praying for the child; burning food, clothes and incense as an offering to the deceased infant; consulting spiritual mediums; and participating in Chao‐du ceremonies for the child's spirit to reach heaven. The families participated in rituals for the benefit of the deceased child and their own. They felt that these rituals would help protect the child from suffering, improve their reincarnation and send their spirit off. Themes that were prevalent within the families were that the rituals help the family cut bonds, do what is best for the deceased infant, avoid bad luck and pray for a successful subsequent pregnancy.

A study limitation is its small sample size with only three racial/ethnic groups represented and interviews from limited participants from each country of origin or cultural group. However, the groups represent a broad range of participants from the Caribbean or Latin American countries, thus adding to our knowledge of death ritual practices in these areas. The focus of the manuscript is to report what the participants identified as ritual practices in their country of origin or in their cultural group. The United States was not their country of origin. While the participants lived in the United States, some of their extended family members did not. Participants reported current ritual practices in their country of origin or in their cultural group that have been carried out generation after generation, across time. Describing rituals in country of origin shows how different the practices of countries of origin are from typical practices in the United States. These practices were continued by participants who now live in the United States. Those traditions are important in clinical practice for providers to deliver culturally sensitive care.

A commonality across cultures is that death rituals help with the grieving process. Based on responses from our study participants, death ritual practices acknowledge the death, legitimize grief, create a safe place for mourners to express emotion and bring together family and friends in support of the bereaved. Bringing together of family and friends with reminiscences of the deceased has been shown to be more helpful to the bereaved than professional counselling (Castle & Phillips, 2003; Doran & Hansen, 2006). A study by Aksoz‐Efe et al. (2018) showed that the bereaved receiving benefits from ritual practices is not only evident in Western culture but is more probably a universal finding which emphasizes how important death ritual practices are after the death of a loved one.

Our study participants shared common celebrations after the death which included music, singing, food and gatherings. Differences were found in the emotional expression of Blacks and Whites, as well as in people from East Asian countries. Our study highlights that practices also differ by religion of the deceased and deceased's family and by the age or generation of the mourner. Of importance is that practices conducted for children differ from those for adults. However, the body of research comparing death rituals across cultures is very scant and speaks to the importance of this study.

The ethnic mix in the United States is changing, making an understanding of different families' practices around major life events even more important. Community health nurses care for families from many different countries and cultures. Nurses who have more understanding of death ritual practices among diverse cultures can be more effective in helping family members feel comfortable in expressing their emotions and feelings (Castle & Phillips, 2003; Robertson et al., 2018). Before and after a patient's death, nurses may become aware of practices that are important to the family and often to the wishes of the deceased.

Family members may feel a lack of understanding and support after their loved one dies if death rituals important to them fail to be acknowledged by the healthcare team. Emphasizing the significance of personal rituals for healthcare providers after the death of their patients may increase their sensitivity with regard to the importance of death rituals for families that have experienced the death of a loved one. Results of a study by Montross‐Thomas et al. (2016) showed that hospice staff and volunteers experienced greater compassion and lower burnout through the use of personal rituals.

A study by Brooten et al. (2016) mentions how difficult it is for parents and family members who have suffered the death of an infant or child to make decisions about the implementation of rituals during such a difficult time. Nurses who have appropriate understanding of practices among different cultures and religions and incorporate family traditions can provide the family with much needed support during this challenging time. Understanding these practices is important in being sensitive and appropriate around the death and in helping other providers understand the practices and not interfere with those that may cause disruption in the families' coping and grieving process.

Acknowledging to the family that families from different countries and cultures often have different practices at this time can help family members feel more comfortable in sharing practices that differ from those common in the United States or by other ethnic/racial or religious groups. Asking the family about specific practices they hope to carry out and noting this in the family's record will help alert providers to the family's wishes at this challenging time, and nurses may gain insight into additional community support needed by the family (Aksoz‐Efe et al., 2018). Nurses can then guide family members to the resources they might have overlooked to help them cope with their grief.

CONFLICT OF INTEREST

All authors have indicated they have no potential conflicts of interest to disclose.

ETHICAL APPROVAL

The study was approved by Florida International University and study site Institutional Review Boards (IRBs) and conformed to US Federal Policy for Protection of Human Subjects.

Appendix S1

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