INTRODUCTION:

Grief is the deep mental and emotional anguish that is a response to the subjective experience of loss of
something significant. Grief is a subjective state of emotional, physical and social responses to the loss of a
valued entity. The loss may be real e.g. death of a loved one, loss of personal possessions or it may be
perceived by the individual alone, unable to be shared by others or identified by others. However, grief can
be expressed by people very differently. Some people do not experience an intense reaction. Most people
experience fluctuating reactions for a period of time while others can develop a complex grief reaction.
Grief is a set of cognitive, emotional and social difficulties that follow the death of a loved one. Grief is a
series of intense physical and psychological responses that occurs following loss. It is a normal, natural,
necessary, and adaptive response to a loss. Grief may be viewed as the subjective states that accompany
mourning, or the emotional work involved in the mourning process. Grief work and the process of mourning
are collectively referred to as the grief response.

ICD-10 CLASSIFICATION:
Comes under adjustment disorder
Grief F43.21
 prolonged F43.29
 reaction F43.20

THEORIES OF THE GRIEVING PROCESS:

Freud proposed the original ‘grief work’ theory, which involved the breaking of ties with the deceased,
readjusting to new life circumstances, and building new relationships.
Kubler-Ross’s Stages of Grieving: Elisabeth Kubler-Ross (1969) established a basis for understanding how
loss affects human life. Kubler-Ross developed a model of five stages to explain what people experience as
they grieve and mourn:
1. Denial is shock and disbelief regarding the loss.
2. Anger may be expressed toward God, relatives, friends, or health care providers.
3. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss.
4. Depression results when awareness of the loss becomes acute.
5. Acceptance occurs when the person shows evidence of coming to terms with death.
Several authors have described grief as a process that includes various stages, characteristic feelings,
experiences, and tasks. Staudacher (1987) states there are three major stages of grief: shock, disorganization,
and reorganization. Westberg (1979) describes ten stages of grief work, beginning with the stage of shock
and progressing through the stages of expressing emotion, depression and loneliness, physical symptoms of
distress, panic, guilt feelings, anger and resentment, resistance, hope, and concluding with the stage of
affirming reality.
Bowlby’s Theory of Attachment Behaviours John Bowlby, a British psychoanalyst, proposed a theory that
humans instinctively attain and retain affectional bonds with significant others through attachment
behaviours, which are crucial to the development of a sense of security and survival. Examples of
attachment behaviours include following, clinging, calling out, and crying. Bowlby saw that human beings
modified these attachment behaviours as they matured from childhood into adulthood, but that patterns of
attachment behaviour formed early endure throughout the life cycle. People experience the most intense
emotions when forming a bond such as falling in love; maintaining a bond such as loving someone;
disrupting a bond such as in a divorce; and renewing an attachment such as resolving a conflict or renewing
a relationship. An attachment that is maintained is a source of security; an attachment that is renewed is a
1
source of joy. When a bond is threatened or broken, however, the person responds with anxiety, protest, and
anger. Actual loss leads to sorrow. According to Bowlby, these emotions reflect affectional bonds. Loss
strongly activates or arouses attachment behaviours. Thus, the clinical picture of increased anxiety, sorrow,
anger, looking for the lost person or object, calling out, crying, and protesting is an attempt to restore the lost
affectional bond through attachment behaviours.
John Bowlby hypothesized four stages in the grief process. He implies that these behaviours can be observed
in all individuals who have experienced the loss of something or someone of value, even in babies as young
as 6 months of age.
● Stage I: Numbness or Protest: This stage is characterized by a feeling of shock and disbelief that the loss
has occurred. The reality of the loss is not acknowledged.
● Stage II: Disequilibrium: During this stage, the individual has a profound urge to recover what has been
lost. Behaviours associated with this stage include a preoccupation with the loss, intense weeping and
expressions of anger toward the self and others, and feelings of ambivalence and guilt associated with the
loss.
● Stage III: Disorganization and Despair: Feelings of despair occur in response to the realization that the loss
has occurred. Activities of daily living become increasingly disorganized, and behaviour is characterized by
restlessness and aimlessness. Efforts to regain productive patterns of behaviour are ineffective and the
individual experiences fear, helplessness, and hopelessness. Somatic complaints are common. Perceptions of
visualizing or being in the presence of that which has been lost may occur. Social isolation is common, and
the individual may feel a great deal of loneliness.
● Stage IV: Reorganization: The individual accepts or becomes resigned to the loss. New goals and patterns
of organization are established. The individual begins a reinvestment in new relationships and indicates a
readiness to move forward within the environment. Grief subsides and recedes into valued remembrances.
George Engel Theory:
● Stage I: Shock and Disbelief: The initial reaction to a loss is a stunned, numb feeling and refusal by the
individual to acknowledge the reality of the loss. Engel states that this stage is an attempt by the individual
to protect the self “against the effects of the overwhelming stress by raising the threshold against its
recognition or against the painful feelings evoked thereby.”
● Stage II: Developing Awareness: This stage begins within minutes to hours of the loss. Behaviours
associated with this stage include excessive crying and regression to a state of helplessness and a childlike
manner. Awareness of the loss creates feelings of emptiness, frustration, anguish, and despair. Anger may be
directed toward the self or toward others in the environment whom the individual holds accountable for the
loss.
● Stage III: Restitution: In this stage, the various rituals associated with loss within a culture are performed.
Examples include funerals, wakes, special attire, a gathering of friends and family, and religious practices
customary to the spiritual beliefs of the bereaved. Participation in these rituals is thought to assist the
individual to accept the reality of the loss and to facilitate the recovery process.
● Stage IV: Resolution of the Loss: This stage is characterized by a preoccupation with the loss. The concept
of the loss is idealized, and the individual may even imitate admired qualities of the lost entity.
Preoccupation with the loss gradually decreases over a year or more, and the individual eventually begins to
reinvest feelings in others.
● Stage V: Recovery: Obsession with the loss has ended, and the individual is able to go on with his or her
life.

2
Table no. 1- Table showing comparison among various theories.
Another theorist, John Harvey (1998), described similar phases of grieving:
1. Shock, outcry, and denial
2. Intrusion of thoughts, distractions, and obsessive review of the loss
3. Confiding in others as a way to emote and to cognitively restructure an account of the loss
Rodebaugh, Schwindt & Valentine (1999) viewed the process of grief as a journey through four stages:
1. Reeling. The person feels shock, disbelief, or denial.
2. Feelings. The person experiences anguish, guilt, profound sadness, anger, lack of concentration,
sleep disturbances, appetite changes, fatigue, and general physical discomfort.
3. Dealing. The person begins to adapt to the loss by engaging in support groups, grief therapy, reading,
and spiritual guidance.
4. Healing. The person integrates the loss as part of life. Acute anguish lessens. Healing does not imply,
however, that the person has forgotten or accepted the loss.

3
Table no. 2- Table showing comparison among various theories.

LENGTH OF THE GRIEF PROCESS:

Length of the grief process depends on the individual and can last for a number of years without being
maladaptive. The acute phase of normal grieving usually lasts 6 to 8 weeks—longer in older adults—but
complete resolution of the grief response may take much longer. Sadock and Sadock (2003) state:
Traditionally, grief lasts about 6 months to 1 year, as the grieving person experiences the calendar year at
least once without the lost person. Some signs and symptoms of grief may persist much longer than 1 or 2
years, and a survivor may have various grief-related feelings, symptoms, and behaviour throughout life. In
general, the acute grief symptoms gradually lessen, and within 1 or 2 months the grieving person is able to
eat, sleep, and return to functioning.

GRIEF REACTION:
Various grief reactions or responses are as follows:
Cognitive Responses to Grief:
The pain that accompanies grieving results from a disturbance in the person’s beliefs (Parkes, 1998). The
sufferer searches for answers to why the trauma occurred. The goal of the search is to give meaning and
purpose to the loss. The nurse might hear the following questions:
• “Why did this have to happen? He took such good care of himself!”
• “Why did such a young person have to die?”
• “He was such a good person! Why did this happen to him?”
Questioning may help the person accept the reality of why someone died. it may include realizing that loss
and death are realities that all must face one day. Others may discover explanations and meaning and even
gain comfort from a religious or spiritual perspective such as believing that the dead person is with God and
at peace (Davis & Nolen-Hoeksema, 2001).
4
Emotional Responses to Grief:
Anger, sadness, and anxiety are the predominant emotional responses to loss. The grieving person may
direct anger and resentment toward the dead person and his or her health practices, family members, or
health care providers or institutions. Common reactions the nurse might hear are as follows:
• “He should have stopped smoking years ago.”
• “If you had taken her to the doctor earlier, this might not have happened.”
• “It took you too long to diagnose his illness.”
Guilt over things not done or said in the lost relationship is another painful emotion. Feelings of hatred and
revenge are common when death has resulted from extreme circumstances such as suicide, murder, or war
(Zisook & Downs, 2000). In a study to assess short-term grief responses after elective abortion, Williams
(2001) noted that some women experience feelings of loss of control, death anxiety, and dependency as well
as feelings of despair and anger.
Spiritual Responses to Grief:
Closely associated with the cognitive and emotional dimensions of grief are the deeply embedded personal
values that give meaning and purpose to life. These values and the belief systems that sustain them are
central components of spirituality and the spiritual response to grief.
Behavioural Responses to Grief:
Behavioural responses to grief are often the easiest to observe. By recognizing behaviours common to
grieving, the nurse can provide supportive guidance for the client’s exploration of emotionally and
cognitively rough terrain. To promote the process, the nurse must provide a context of acceptance in which
the client can explore his or her behaviour. Tearfully sobbing, crying uncontrollably, showing great
restlessness, and searching are evidence of yearning and seeking.
Physiologic Responses to Grief:
Physiologic symptoms and problems associated with grief responses are often a source of anxiety and
concern for the grieving person as well as friends or caregivers. Those grieving may complain of insomnia,
headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the
immune and endocrine systems. Sleep disturbances are among the most frequent and persistent bereavement
associated symptoms (Zisook & Downs, 2000).
While assessing for grief, the nurse has to follow Cultural Considerations:
• Universal Reactions to Loss
• Culture-Specific Rituals

5
Table no. 3- Table showing various dimensions of responses
Title: Emotional and physiological reactivity in Complicated Grief
Authors: LeBlanc N, Unger L, McNally R
Place: Department of Psychology, Harvard University, United States
Researcher recruited a sample of 23 bereaved adults with complicated grief and 26 healthy bereaved adults
to complete an emotional reactivity paradigm. Participants watched a series of emotional film clips and
provided measures of their self-reported emotional response. They also assessed their heart rate, respiratory
sinus arrhythmia (RSA), and skin conductance level in response to these clips. Results shown that though
emotional and physiological differences between the groups were rare, the CG group exhibited attenuated
RSA reactivity to some emotional film clips, suggesting blunted parasympathetic nervous system reactivity
in those with the disorder. Individuals with CG do not exhibit pervasive differences in emotional and
physiological reactivity compared to healthy bereaved individuals. However, they did observe evidence of
blunted parasympathetic nervous system reactivity in individuals with CG, which may mediate emotional
inflexibility among those who develop the disorder.

6
TYPES OF GRIEF:
Anticipatory Grief:
Anticipatory grief has been defined as "the total set of cognitive, affective, cultural, and social reactions to
expected death felt by the patient and family." The following aspects of anticipatory grief have been
identified among survivors:
• Depression.
• Heightened concern for the dying person.
• Attempts to adjust to the consequences of the death.
Anticipatory grief provides family members with time to gradually absorb the reality of the loss. Individuals
are able to complete unfinished business with the dying person (e.g., saying "good-bye," "I love you," or "I
forgive you").
Prolonged Grief:
It is characterized by an intense preoccupation with memories of the lost entity for many years after the loss
has occurred. A prolonged process may be considered maladaptive when certain behaviours are exhibited.
Prolonged grief may be a problem when behaviours such as maintaining personal possessions aimed at
keeping a lost loved one alive (as though he or she will eventually re-enter the life of the bereaved) or
disabling behaviours that prevent the bereaved from adaptively performing activities of daily living are in
evidence.
Delayed or Inhibited Grief:
The individual becomes fixed in the denial stage of the grieving process. Delayed or inhibited grief refers to
the absence of evidence of grief when it ordinarily would be expected. The emotional pain associated with
loss is not experienced, but there may be evidence of anxiety disorders or sleeping disorders. The individual
may remain in denial for many years until the grief response is triggered by a reminder of the loss or even by
another unrelated loss. Delayed grieving most commonly occurs because of ambivalent feelings toward that
which has been lost, outside pressure to resume normal function, or perceived lack of internal and external
resources to cope with a profound loss.
Distorted (Exaggerated) Grief:
The individual who experiences a distorted response is fixed in the anger stage of grieving. The normal
behaviours associated with grieving, such as helplessness, hopelessness, sadness, anger and guilt are
exaggerated out of proportion to the situation. The individual turns the anger inward on the self and is unable
to function in normal activities of daily living. Pathological depression is a distorted grief response. In the
distorted grief reaction, all of the symptoms associated with normal grieving are exaggerated. Feelings of
sadness, helplessness, hopelessness, powerlessness, anger, and guilt, as well as numerous somatic
complaints, render the individual dysfunctional in terms of management of daily living. Murray and Zentner
(2001) describe an exaggerated grief reaction in the following way: An intensification of grief to the point
that the person is overwhelmed, demonstrates prolonged maladaptive behaviour, manifests excessive
symptoms and extensive interruptions in healing, and does not progress to integration of the loss, finding
meaning in the loss, and resolution of the mourning process.
Disenfranchised Grief:
Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or
supported socially. Three categories of circumstances can result in disenfranchised grief:
• A relationship has no legitimacy.
• The loss itself is not recognized.
7
• The griever is not recognized.
In each situation, there was an attachment followed by a loss that leads to grief. The grief process is more
complex because the usual supports that facilitate grieving and the healing process are absent (Lenhardt,
1997).
Title: Disenfranchised Grief in the PICU: Crying for Attention.
Author: Crowe S
Place: Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.
The relationship between the child and the staff caring for the child is not acknowledged to the same extent,
and this may cause difficulties for staff who grieve following the death of the child. This experience is
repeated many times when working in the PICU. This article describes two cases that illustrate the
unrecognized nature of disenfranchised grief for paediatric healthcare staff. Addressing the cumulative
effects of bereavement on the staff in the PICU through formal and informal systems of support may reduce
emotional exhaustion, improve staff retention, and enhance the care of children and families.
Complicated Grief:
Some believe complicated grieving to be a response outside the norm and occurring when a person is void of
emotion, grieves for prolonged periods, or has expressions of grief that seem disproportionate to the event.
People may suppress emotional responses to the loss or become obsessively preoccupied with the deceased
person or lost object. Others actually may suffer from clinical depression when they cannot make progress in
the grief process (Enright & Marwit, 2002).

NORMAL GRIEF VS DEPRESSION:

Table no. 4- Table showing difference between normal grief and clinical depression.

Title: Is pathological grief lasting more than 12 months grief or depression?

Author: Bryant R
Place: School of Psychology, University of New South Wales, New South Wales, Australia
Multiple studies indicate that, more than 6 months after bereavement, 10-15% of bereaved people experience
marked impairment secondary to severe grief responses. This response is characterized by intense yearning
for the deceased together with related symptoms, is noted across cultures and age groups, is distinct from
depression and anxiety, and contributes to psychiatric morbidity, poor health behaviours, physical illnesses,
and occupational and social dysfunction. Psychotherapeutic interventions targeted at the core symptoms of
prolonged grief show promising results, in contrast to poor response to psychotherapy and pharmacological
interventions targeted at depression. There is convergent evidence that introducing psychiatric diagnoses to
identify bereaved people suffering prolonged severe grief responses addresses a major public health issue, is
8
supported by convergent evidence, and has the potential to minimize inappropriate treatment as a result of
misdiagnosis.

GRIEF RESPONSES OVER THE LIFE SPAN:

Birth to Age 2:
Infants are unable to recognize and understand death, but they can experience the feelings of loss and
separation. Infants who are separated from their mother may become quiet, lose weight, and sleep less.
Children at this age will likely sense changes in the atmosphere of the home where a death has occurred.
They often react to the emotions of adults by becoming more irritable and crying more.
Ages 3 to 5:
They believe death is reversible, and their thoughts about death may include magical thinking. For example,
they may believe that their thoughts or behaviours caused a person to become sick or to die. Children of this
age are capable of understanding at least some of what they see and hear from adult conversations or media
reports. They become frightened if they feel a threat to themselves or their loved ones. They are concerned
with safety issues and require a great deal of personal reassurance that they will be protected. Regressive
behaviours, such as loss of bladder or bowel control, thumb sucking, and temper tantrums are common.
Changes in eating and sleeping patterns may also occur.
Ages 6 to 9:
Children at this age are beginning to understand the finality of death. They are able to understand a more
detailed explanation of why or how a person died, although the concept of death is often associated with old
age or with accidents. They may believe that death is contagious and avoid association with individuals who
have experienced a loss by death. Death is often personified, in the form of a monster. Normal grief
reactions at this age include regressive and aggressive behaviours, withdrawal, school phobias, somatic
symptoms, and clinging behaviours.
Ages 10 to 12:
Preadolescent children are able to understand that death is final and eventually affects everyone, including
themselves. They are interested in the physical aspects of dying and the final disposition of the body. They
may ask questions about how the death will affect them personally. Feelings of anger, guilt, and depression
are common. Peer relationships and school performance may be disrupted. There may be a preoccupation
with the loss and a withdrawal into the self. They will require reassurance of their own safety and self-worth.
Adolescents:
Adolescents are usually able to view death on an adult level. They understand death to be universal and
inevitable. They have difficulty tolerating the intense feelings associated with the death of a loved one. They
may withdraw into themselves. Some teens exhibit acting-out behaviours, such as aggression and defiance. It
is often easier for adolescents to discuss their feelings with peers than with their parents or other adults.
Some adolescents may show regressive behaviours, whereas others react by trying to take care of their loved
ones who are also grieving.
Adults:
The adult’s concept of death is influenced by cultural and religious backgrounds (Murray & Zentner, 2001).
Behaviours associated with grieving in the adult were discussed in the section on “Theoretical Perspectives
on Loss and Bereavement.”
Old Age:

9
By the time individuals reach their 60s and 70s, they have experienced numerous losses, and mourning has
become a lifelong process. Unfortunately, with the aging process comes a convergence of losses, the timing
of which makes it impossible for the aging individual to complete the grief process in response to one loss
before another occurs. Because grief is cumulative, this can result in bereavement overload, which has been
implicated in the predisposition to depression in the elderly.

NURSING MANAGEMENT:
Normal grief does not require any treatment while complicated grief requires medication depending on the
prevailing behaviour responses.
Assessment:
Effective assessment involves observing all dimensions of human response: what the person is thinking
(cognitive), how the person is feeling (emotional), what the person’s values and beliefs are (spiritual), how
the person is acting (behavioural), and what is happening in the person’s body (physiological). Effective
communication skills during assessment can lead the client toward understanding his or her experience.
Thus, assessment facilitates the client’s grief process. While observing for client responses in the dimensions
of grieving, the nurse explores three critical components in assessment:
• Adequate perception regarding the loss
• Adequate support while grieving for the loss
• Adequate coping behaviours during the process
Nursing Diagnosis:
• Risk for complicated grieving related to loss of a valued concept/object; loss of a loved one
• Risk for spiritual distress related to complicated grief process
Outcome Identification:
The following criteria may be used for measurement of outcomes in the care of the grieving client:
The client:
• Acknowledges awareness of the loss.
• Is able to express feelings about the loss.
• Verbalizes stages of the grief process and behaviours associated with each.
• Expresses personal satisfaction and support from spiritual practices.
Nursing Interventions:
• Provide an open accepting environment.
• Assess client’s stage in the grief process.
• Encourage ventilation of feelings and listen actively.
• Support patient and significant others share mutual fears, concerns, plans, and hopes for each other.
• Provide various diversional activities.
• Encourage significant others to manage their own self-care needs for rest, sleep, nutrition, leisure
activities, and time away from the patient.
• Provide teaching about common symptoms of grief.
• Reinforce goal-directed activities.
• Consider the patient’s or family’s denial about the loss for it is part of the grieving process.
• Bring together similar aggrieved persons, to encourage communication, share experiences of the loss
and to offer companionship, social and emotional support.
• Anticipate increased or exaggerated affective behaviour.
• Communicate therapeutically with patient and family members and allow them to verbalize feelings.
10
Title: Helpfulness of nursing actions to suddenly bereaved family members in an accident and
emergency setting in Hong Kong.
Author: Li S, Chan C, Lee DT.
Place: Accident and Emergency (A & E) Department, United Christian Hospital, Hong Kong, China
The study aimed to gain knowledge about what nursing actions bereaved family members in Hong Kong
perceived as helpful. This study was exploratory and descriptive in nature, and used a quantitative approach.
Data were collected through structured telephone interviews.
Seventy-six bereaved subjects were recruited in an A & E department in Hong Kong. The subjects perceived
written information, opportunity to view the deceased, and respecting individual customs and religious
procedures as most helpful and offering sedation, discouraging viewing of the body, and providing comfort
measures as most unhelpful. No statistically significant differences among the overall mean of helpful
nursing actions according to the subjects' age, gender, education level, family income and religions were
found. Significant correlations between some actions and the respondents' age, family income and
educational level were found.
Title: Analysing the role played by district and community nurses in bereavement support
Author: Johnson A
Place: Department of Clinical Health Care, Faculty of Health and Life Sciences, Oxford Brookes University
This article explores bereavement support as one of the roles of the district nurse (DN) and community nurse
(CN). Bereavement support is considered part of palliative care, which is a major role for all nurses.
Bereavement can result in depression, stress-related disorders, and high mortality; it is therefore imperative
to understand the complexities, theoretical aspects, and implications of poor service provision. Palliative
care is one of the primary roles of a DN, and it largely involves emotional support. It has been shown that
DNs lack confidence and the skills to provide bereavement support to families and carers of palliative care
patients. Education, training, and time management are the main determinants of effective bereavement
support. The need is to develop a standard collaborative approach to bereavement support and incorporate it
into the palliative care role of DNs.

OTHER RESEARCH UPDATES:

Title: Breast cancer: Is grief a risk factor?
Authors: Paula N, Martins J, Amaral L, Rhana P, Tavares E, Leite W, Tavares G, Rodrigues A.
Place: School of Human, Social and Health Sciences, Fumec University, Belo Horizonte, MG, Brasil.
Study shows that in addition to hereditary factors, lifestyle and environmental factors, there are factors
related to emotional distress (mourning), which interfere with the development of breast cancer. Thus, it is
necessary to investigate if the experience of mourning can trigger the appearance of the tumour. For this, an
integrative review was performed to verify the existence of the relationship between mourning and
development of breast cancer. A possible mechanism involving cortisol release has been proposed, but more
research is needed to make it clear whether the association between mourning and breast cancer really exists,
and by what path.
Title: Nurses' Experiences of Grief Following Patient Death: A Qualitative Approach.
Authors: Khalaf I, Al-Dweik G, Abu-Snieneh H, Al-Daken L et-al.
11
Place: The University of Jordan.
A qualitative design guided by a phenomenological approach was adopted. Data were collected from a
purposive sample of 21 Jordanian nurses by conducting three focus groups and analysed using Colaizzi's
framework.
Four themes were generated in which participants reported feelings of grief following their patients' death.
Their grief emotions were reported as sadness, crying, anger, shock, denial, faith, fear, guilt, fear of the
family's reaction, and powerlessness.
The study provided evidence that nurses respond emotionally to patients' death and experience grief. Nurses
are burdened by recurrent patients' deaths and try to cope and overcome their grief. This study emphasizes
the importance of developing strategies to help nurses positively cope with their grief from a holistic
perspective. This will reflect positively on the nurses' performance.
Title: Can Grief be a Mental Disorder?: An Exploration of Public Opinion
Author: Breen L, Penman E, Prigerson H, Hewitt L.
Place: School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Western
Australia.
International sample of 348 participants from a wide range of cultures was asked if certain expressions of
grief could be considered a mental disorder and to explain their answer. Analysis revealed that the majority
(74.7%) agreed that grief could be considered a mental disorder. The presence of pervasive distress, of harm
to self and/or others, functional impairment, and persistent grief were described as the circumstances under
which grief can be a mental disorder. Reasons grief is not a mental disorder were that it is normal,
temporary, in response to an event, and that efforts to include it in diagnostic manuals will lead to
medicalization and stigma.

SUMMARY:
Grief is a subjective state of emotional, physical and social response to the loss of a valued entity. The loss
may be real, in which case it can be substantiated by others (e.g. death of a loved one), or perceived by the
individual alone, in which case it cannot be perceived or shared by others (e.g. loss of feeling of femininity
following mastectomy). Grief comes under adjustment disorder F43.21 of ICD-10 classification. Various
theorists gave their theories on grief. Most popular theory of grief reaction is given by Kubler Ross. Grief
responses may be adaptive or maladaptive.

12
BIBLIOGRAPHY:
1. Videbeck S. Psychiatric-mental health nursing. 3rd ed. [Place of publication not identified]: Wolters
kluwer; 2017.p357-380.
2. Shives. Basic Concepts of Psychiatric-Mental Health Nursing. Lippincott, Williams & Wilkins;p532-
56.
3. Townsend MC. Psychiatric Mental Health Nursing. 8th ed. New Delhi: Jaypee Brothers Medical
Publishers; 2015. p54-59.
4. Stuart GW. Principles and Practice of Psychiatric Nursing. 10th ed. Missouri: Elsevier; 2013. p.238-
42.
5. Sadock JB. Sadock VA. Ruiz P. Synopsis of Psychiatry. 11th ed. Philadelphia: Wolters kluwer; 2015.
P443-47.
6. Sreevani R. A guide to mental health and psychiatric nursing, 4th ed. Jaypee brothers
publication2016; P72-78.
7. Gelder G. Michael, Anderson C. Nancy, Geddes R. John. New oxford textbook of psychiatry. 2nd ed.
Oxford universal press2012.p765-770.
8. Grieiving Nursing Diagnosis and Care Plan [Internet]. Nurseslabs. 2019 [cited 16 September 2019].
Available from: https://nurseslabs.com/grieving/
9. Paula N, Martins J, Amaral L, Rhana P, Tavares E, Leite W et al. Breast cancer: Is grief a risk
factor?. Revista da Associação Médica Brasileira [Internet]. 2018 [cited 16 September
2019];64(7):595-600. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30365661
10. LeBlanc N, Unger L, McNally R. Emotional and physiological reactivity in Complicated Grief.
Journal of Affective Disorders [Internet]. 2016 [cited 16 September 2019];194:98-104. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/26803781
11. Khalaf I, Al-Dweik G, Abu-Snieneh H, Al-Daken L, Musallam R, BaniYounis M et al. Nurses’
Experiences of Grief Following Patient Death: A Qualitative Approach. Journal of Holistic Nursing
[Internet]. 2017 [cited 16 September 2019];36(3):228-240. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/28845718
12. Crowe S. Disenfranchised Grief in the PICU. Pediatric Critical Care Medicine [Internet]. 2017 [cited
16 September 2019];18(8):e367-e369. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/28562429
13. Bryant R. Is pathological grief lasting more than 12 months grief or depression?. Current Opinion in
Psychiatry [Internet]. 2013 [cited 16 September 2019];26(1):41-46. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23196998
14. Breen L, Penman E, Prigerson H, Hewitt L. Can Grief be a Mental Disorder?. The Journal of
Nervous and Mental Disease [Internet]. 2015 [cited 16 September 2019];203(8):569-573. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/26226240
15. Li S, Chan C, Lee D. Helpfulness of nursing actions to suddenly bereaved family members in an
accident and emergency setting in Hong Kong. Journal of Advanced Nursing [Internet]. 2002 [cited
16 September 2019];40(2):170-180. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/12366647
16. Johnson A. Analysing the role played by district and community nurses in bereavement support.
British Journal of Community Nursing [Internet]. 2015 [cited 17 September 2019];20(6):272-277.
Available from: https://www.ncbi.nlm.nih.gov/pubmed/26043011
17. When Shekhar Suman And Alka Suman's 1st Child Died, Both Went Into Depression And Wanted
To End Life - Bollywoodshaadis | DailyHunt [Internet]. Dailyhunt. 2019 [cited 17 September 2019].
13
Available from: https://m.dailyhunt.in/news/india/english/bollywoodshaadis-epaper-
bshadi/when+shekhar+suman+and+alka+suman+s+1st+child+died+both+went+into+depression+and
+wanted+to+end+life-newsid-89646443

14