NRG 305: Care with Patients with Maladaptive Patterns of Behavior

LECTURE 5: GRIEF AND LOSS

AUHREEN M. ORIA I LEC
2nd SEMESTER I S.Y 2024 I MIDTERM: WEEK 5

COURSE OUTLINE: MIDTERM • Anticipatory grieving - when people facing an

1. Loss imminent loss begin to grapple with the very real
2. Types of Losses possibility of the loss or death in the near future.
3. Grieving Process • Mourning - is the outward expression of grief.
4. Dimensions of Grieving
5. Disenfranchised Grief THEORIES OF GRIEVING (Kubler-Ross’s Stages of
6. Complicated Grieving Grieving)
7. Application of Nursing Process D-A-B-D-A
• Denial - is shock and disbelief regarding the loss
• Anger - may be expressed toward God, relatives,
“What we once enjoyed and deeply loved we can never lose, friends, or healthcare providers.
for all that we love deeply becomes part of us” – Helen Keller
• Bargaining - occurs when the person asks God or
fate for more time to delay the inevitable loss.
“Death is a challenge. It tells us not to waste time. It tells us to
• Depression - results when awareness of the loss
tell each other right now that we love each other.” – Leo
becomes acute.
Buscaglia
• Acceptance - occurs when the person shows
evidence of coming to terms with death.
LOSS
• Experiences of loss are normal and essential in THEORIES OF GRIEVING (Bowlby’s Phases of Grieving)
human life. Letting go, relinquishing, and moving on
are unavoidable passages as a person moves through 4 Phases of Grieving
1. Experiencing numbness and denying the loss
the stages of growth and development. People
2. Emotionally yearning for the lost loved one and
frequently say goodbye to places, people, dreams, and
familiar objects. protesting the permanence of the loss
3. Experiencing cognitive disorganization and
emotional despair with difficulty functioning in the
TYPES OF LOSSES everyday world
4. Reorganizing and reintegrating the sense of self to
LOSSES RELATED TO MASLOW’S HIERARCHY
pull life back together
• Physiologic Loss - examples: amputation,
mastectomy or hysterectomy or loss of mobility THEORIES OF GRIEVING (Engel’s Stages of Grieving -
• Safety Loss - loss of safe environment: domestic 1964)
violence, child abuse or public violence 5 Stages of Grieving
• Loss of Security and sense of belonging - 1. Shock and Disbelief
changes in relationship (birth, marriage, divorce, 2. Developing Awareness
illness and death) 3. Restitution
• Loss of Self-esteem - change in how a person is 4. Resolution of the loss
valued at work or in relationships or by himself or 5. Recovery
herself can threaten self-esteem
• Loss related to self-actualization - an external or THEORIES OF GRIEVING (Horowitz’s Stages of Loss and
internal crisis that blocks or inhibits strivings toward Adaptation)
fulfillment may threaten personal goals and individual 5 Stages of Loss and Adaptation
potential 1. Outcry
2. Denial and intrusion
GENERAL TYPES OF LOSSES 3. Working through
• Actual loss - can be recognized by others 4. Completion
• Perceived loss - is felt by person but intangible to
others
• Physical loss vs. psychological loss (may be
both) - psychological loss may be caused by an
altered self-image
• Maturational loss - experienced as a result of
natural development process
• Situational loss - experienced as a result of an
unpredictable event
• Anticipatory loss - loss has not yet taken places

Regardless of the type of loss, nurses must have a basic

understanding of what is involved to meet the challenge that
grief brings to clients

TASKS OF GRIEVING
THE GRIEVING PROCESS • Grieving tasks, or mourning - it is sometimes
• Grief - refers to the subjective emotions and affect called “grief work” because it is difficult and requires
that are a normal response to the experience of loss. tremendous effort and energy to accomplish
• Grieving/bereavement - refers to the process by
which a person experiences the grief.

1 l Transcripted for educational by: Khelzy A. De Gracia, SN

Note: For educational purpose only. No copyright infringement intended.
RANDO’S (1984) “SIX Rs” DESCRIPTION OF TASK OF • Essential nursing aspect of care: Ministering to the
GRIEVING spiritual needs of those grieving
1. Recognize • Nurses can promote a sense of well-being
2. React • Finding explanations and meaning through religious
3. Recollect and re-experience or spiritual beliefs, the client may begin to identify
4. Relinquish positive aspects of grieving.
5. Readjust
6. Reinvest BEHAVIORAL RESPONSES TO GRIEF (easiest to
observe)
WORDEN (2008) VIEWS THE TASKS OF GRIEVING AS • Tearfully sobbing, crying uncontrollably, showing
FOLLOWS: great restlessness, and searching are evidence of
1. Accepting the reality of the loss the outcry of emotions.
2. Working through the pain of grief • Irritability and hostility toward others reveal anger
3. Adjusting to an environment that has changed and frustration in the process.
because of the loss • Drug or alcohol abuse
4. Emotionally relocating that which has been lost and • Suicide and homicide attempts
moving on with life • In the phase of reorganization, or recovery, the
bereaved person participates in activities and
DIMENSIONS OF GRIEVING reflection that are personally meaningful and
• People have many and varied responses to loss. satisfying.
They express their bereavement in their thoughts,
words, feelings, and actions as well as through their PHYSIOLOGICAL RESPONSES TO GRIEF
physiologic responses. • Physiologic symptoms and problems associated with
grief responses are often a source of anxiety and
RESPONSES concern for the grieving person as well as for friends
• Cognitive or caregivers
• Emotional Responses:
• Spiritual • Insomnia; Sleep disturbances are among the most
• Behavioral frequent and persistent bereavement associated
• Physiological symptoms (Sadock et al., 2015).
• Headaches,
COGNITIVE RESPONSES TO GRIEF • Impaired appetite,
Grieving often causes a person to change beliefs about self • Weight loss,
and the world: • Lack of energy,
• The world’s benevolence, • Palpitations,
• The meaning of life as related to justice, • Indigestion,
• and a Sense of destiny or life path. • and Changes in the immune and endocrine systems.
Other changes:
• Reviewing and ranking values, CULTURAL CONSIDERATIONS
• Becoming wiser,
• Shedding illusions about immortality, UNIVERSAL REACTIONS TO LOSS
• Viewing the world more realistically, • Each culture defines the context in which grieving,
• and Reevaluating religious or spiritual beliefs mourning, and integrating loss into life are given
(Sadock et al., 2015). meaningful expression.
• Universal reactions:
• Questioning and trying to make sense of the loss ➢ initial response of shock and social
• Attempting to keep the lost one present disorientation,
➢ attempts to continue a relationship with the
EMOTIONAL RESPONSES TO GRIEF deceased,
1. Anger, sadness, and anxiety are the predominant ➢ anger with those perceived as responsible
emotional responses to loss. for the death,
2. Guilt over things not done or said in the lost ➢ and a time for mourning.
relationship is another painful emotion.
3. Emotional responses are evident throughout the CULTURE-SPECIFIC RITUALS
grieving process. • Because cultural bereavement rituals have roots in
4. Eventually, reality begins to set in. several of the world’s major religions (i.e., Buddhism,
5. In understanding the loss’s permanence, he or she Christianity, Hinduism, Islam, Judaism), religious or
recognizes that patterns of thinking, feeling, and spiritual beliefs and practices regarding death
acting attached to life with the deceased must frequently guide the client’s mourning.
change.
6. Eventually, the bereaved person begins to African Americans Muslim Americans
reestablish a sense of personal identity, direction, • Catholic and • Do not permit
and purpose for living. Episcopalian cremation
services, hymns may • It is important to follow
SPIRITUAL RESPONSES TO GRIEF be sung, poetry read, the five steps of burial
• Closely associated with the cognitive and emotional and a eulogy spoken; procedure
dimensions of grief are the deeply embedded • less formal Baptist • Specify washing,
personal values that give meaning and purpose to and Holiness dressing, and
life. traditions may involve positioning of the
• During loss, it is within the spiritual dimension of singing, speaking in body.
human experience that a person may be most tongues, and liturgical • The first step is
comforted, challenged, or devastated dancing. traditional washing of
2 l Transcripted for educational by: Khelzy A. De Gracia, SN
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• Viewing in church the body by a Muslim deceased of the
• Mourning also may be of the same gender arrival.
expressed through (Morrisey, 2014).
public prayers, black Native Americans Orthodox Jewish
clothing, and Americans
decreased social • A tribe’s medicine • A relative to stay with
activities. man or priestly healer, a dying person so that
• May last a few weeks who assists the the soul does not
to several years friends and family of leave the body while
the deceased to the person is alone.
Haitian Americans Chinese Americans regain their spiritual • The family of the
• Practice vodun • Have strict norms for equilibrium, is an deceased may
(voodoo), also called announcing death, essential spiritual request to cover the
“root medicine.” preparing the body, guide. body with a sheet.
• This practice can be arranging the funeral • To designate the end • The eyes of the
found in several states and burial, and of mourning, a deceased should be
(Alabama, Louisiana, mourning after burial. ceremony at the burial closed, and the body
Florida, North • Burning incense and grounds is held during should remain
Carolina, South reading scripture are which the grave is covered and
Carolina, and Virginia) ways to assist the covered with a blanket untouched until family,
and in some spirit of the deceased or cloth for making a rabbi, or a Jewish
communities within in the afterlife journey. clothes. undertaker can begin
New York City. • If Buddhists, • Later, the cloth is rites.
meditating before a given to a tribe • Autopsy is not
shrine in the room is member. A dinner permitted (unless
important. featuring singing, required by law);
• For 1 year after death, speechmaking, and • Burial must occur
the family may place contributing money within 24 hours unless
bowls of food on a completes the delayed by the
table for the spirit. ceremony. Sabbath

Japanese Americans Filipino Americans NURSE’S ROLE

• Buddhist Japanese • Wearing black • In extended families, varying expressions and
Americans view death clothing or armbands responses to loss can exist depending on the degree
as a life passage is customary during of acculturation to the dominant culture of society.
• Close family members mourning. Rather than assuming that he or she understands a
may bathe the • Places wreaths on the particular culture’s grieving behaviors, the nurse
deceased with warm casket and drape a must encourage clients to discover and use what is
water and dress the broad black cloth on effective and meaningful for them.
body in a white the home of the
kimono after deceased. DISENFRANCHISED GRIEF
purification rites. • Family members Circumstances that can result in disenfranchised grief
• For 2 days, family and commonly place include:
friends bearing gifts announcements in • A relationship that has no legitimacy
may visit or offer local newspapers • The loss itself is not recognized
money for the asking for prayers and • The griever is not recognized
deceased while blessings on the soul • The loss involves social stigma
saying prayers and of the deceased.
burning incense. A RELATIONSHIP THAT HAS NO LEGITIMACY
• Possible examples include same-sex relationships
Vietnamese Americans Hispanic Americans (Mortell, 2015), cohabitation without marriage, and
• Predominantly • They are extramarital affairs.
Buddhist predominately Roman
• Bathe the deceased Catholic THE LOSS ITSELF IS NOT RECOGNIZED
and dress him or her • They may pray for the • Prenatal death, abortion, relinquishing a child for
in black clothes. soul of the deceased adoption, death of a pet, or other losses not involving
• May put a few grains during a novena (9- death, such as job loss, separation, divorce, and
of rice in the mouth day devotion) and a children leaving home.
and place money with rosary (devotional
the deceased so that prayer). THE GRIEVER IS NOT RECOGNIZED
he or she can buy a • They manifest luto
• Older adults and children experience limited social
drink as the spirit (mourning) by wearing
recognition for their losses and the need to mourn
moves on in the black or black and
• Nurses and hospital chaplains
afterlife. white while behaving
• Family members of someone incarcerated or
• The body may be in a subdued manner.
executed for crimes
displayed for viewing • Friends and relatives
in the home before bring flowers and
burial. crosses to decorate COMPLICATED GRIEVING
• When friends enter, the grave. • Response outside the norm
music is played as a • Occurs: when a person is void of emotion, grieves for
way to warn the prolonged periods, or has expressions of grief that
seem disproportionate to the event.

3 l Transcripted for educational by: Khelzy A. De Gracia, SN

Note: For educational purpose only. No copyright infringement intended.
 • People may suppress emotional responses to the
loss or become obsessively preoccupied with the
deceased person or lost object.
• May suffer from clinical depression when they cannot
make progress in the grief process
COMPLICATED GRIEVING AS A UNIQUE AND VARIED
EXPERIENCE
Physical reactions can include:
• An impaired immune system,
• Increased adrenocortical activity,
• Increased levels of serum prolactin and growth
hormone,
• Psychosomatic disorders, and
• Increased mortality from heart disease
Characteristic emotional responses include:
• Depression,
• Anxiety or panic disorders,
• Delayed or inhibited grief, and chronic grief
(Burke et al., 2014)

“Grief is like the ocean, it comes in waves, ebbing and flowing.

Sometimes the water is calm, and sometimes it is
overwhelming. All we can do is learn to swim.” – Vicki Harrison

APPLICATION OF NURSING PROCESS

Factors that influence the grieving person’s return to
homeostasis:
• Adequate perception of the situation
• Adequate situational support
• Adequate coping
Nurse’s characteristics to support and facilitate grieving
process:
Must:
• Observe and listen for cognitive, emotional, spiritual,
behavioral, and physiologic cues.
• Must be familiar with the phases, tasks, and
dimensions of human response to loss
• Realize that each client’s experience is unique.
• Skillful communicator
• Examine his or her own personal attitudes, maintain
an attentive presence, and provide a
psychologically safe environment for deeply intimate
sharing.
• Creates a safe environment

CHARACTERISTICS OF SUSCEPTIBILITY ASSESSMENT

Effective assessment involves observing all dimensions
• Low self-esteem
of human response:
• Low trust in others
• Cognitive
• A previous psychiatric disorder
• Emotional
• Previous suicide threats or attempts
• Spiritual
• Absent or unhelpful family members
• Behavioral
• An ambivalent, dependent, or insecure attachment to
• Physiological
the deceased person.

• Ambivalent attachment, at least one partner is

Cognitive • Disruption of assumptions and
responses beliefs
unclear about how the couple loves or does not love
each other • Questioning and trying to make
• Dependent attachment, one partner relies on the sense of the loss
other to provide for his or her needs without • Attempting to keep the lost one
necessarily meeting the partner’s needs present
• Insecure attachment, usually forms during • Believing in an afterlife and as
childhood, especially if a child has learned fear and though the lost one is a guide
helplessness (i.e., through intimidation, abuse, or Emotional • Anger, sadness, anxiety
control by parents) responses • Resentment
• Guilt
CHARACTERISTICS OF SUSCEPTIBILITY • Feeling numb
• Death of a spouse or child • Vacillating emotions
• Death of a parent (particularly in early childhood or • Profound sorrow, loneliness
adolescence) • Intense desire to restore bond
• Sudden, unexpected, and untimely death with lost one or object
• Multiple deaths • Depression, apathy, despair
• Death by suicide or murder during phase of disorganization
• Sense of independence and
confidence as phase of
reorganization evolves

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Note: For educational purpose only. No copyright infringement intended.
 Spiritual • Disillusioned and angry with god
responses • Anguish of abandonment or
perceived abandonment
• Hopelessness,
meaninglessness
• Functioning “automatically”
• Tearful sobbing, uncontrolled
crying
• Great restlessness, searching
behaviors
• Irritability and hostility
• Seeking and avoiding places
and activities shared with lost
one
• Keeping valuables of lost one
while wanting to discard them
• Possibly abusing drugs or
alcohol
• Possible suicidal or homicidal
gestures or attempts
• Seeking activity and personal
reflection during phase or
reorganization
Behavioral • Headaches, insomnia
responses • Impaired appetite, weight loss
• Lack of energy
• Palpitations, indigestion
• Changes in immune and
endocrine systems
The nurse should explore three critical components in
assessment:
• Adequate perception regarding the loss
• Adequate support while grieving for the loss
• Adequate coping behaviors during the process
PERCEPTION OF THE LOSS
Scenario and dialogue:
• The doctor has just informed Ms. Morrison that the
lump on her breast is cancerous and that she can be
scheduled for a mastectomy in 2 days. The nurse
visits the client after rounds and finds her quietly
watching television.
• Later in the shift, the nurse finds Ms. Morrison hitting
her pillow and crying. She has eaten little food and
has refused visitors
SUPPORT
COPING BEHAVIORS
• The following day, the nurse has heard in report that
Ms. Morrison had a restless night. She enters Ms.
Morrison’s room and sees her crying with a full tray
of food untouched
The critical factors of perception, support, and coping are
interrelated as well and provide a framework for assessing
and assisting the client.
DATA ANALYSIS AND PLANNING
The nurse must base nursing diagnosis for the person
experiencing loss on subjective and objective
assessment data.
Nursing diagnosis used for clients experiencing grief include:
• Grieving
• Complicated grieving
• Risk for complicated grieving
• Anticipatory grieving
OUTCOME IDENTIFICATION
Example of outcomes are as follows
The client will:
• Identify the effects of his or her loss.
• Identify the meaning of his or her loss.
• Seek adequate support while expressing grief.
• Develop a plan for coping with the loss.
• Apply effective coping strategies while expressing
and assimilating all dimensions of human response
to loss in his or her life.
• Recognize the negative effects of the loss on his or
her life.
• Seek or accept professional assistance if needed to
promote the grieving process.
INTERVENTIONS
Exploring the Perception of Loss:
• First step that can help alleviate the pain of what
some would call the initial emotional overload in
grieving.
• The nurse might ask what being alone means to the
person and explore the possibility of others being
supportive
• It is particularly important that the nurse listens to
whatever emotions the person expresses, even if the
nurse doesn’t “agree” with the feelings.
• It is essential to accept the person’s feelings without
trying to dissuade them from feeling angry or upset.
• The nurse needs to encourage the person to express
any and all feelings without trying to calm or placate
them.
• Effective communication skills can be useful in
helping the client in adaptive denial move toward
acceptance.
5 l Transcripted for educational by: Khelzy A. De Gracia, SN
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Scenario and dialogue:
• The nurse enters Ms. Morrison’s room and sees her
crying and her full tray of food untouched.
NURSING INTERVENTIONS
For Grief
Obtaining Support:
• The nurse can help the client to reach out and accept
what others want to give in support of his or her
grieving process. Note the assessment is
developed into a plan for support.
Scenario and dialogue:
• Many Internet resources are available to nurses who
want to help a client find information, support groups,
and activities related to the grieving process.
Promoting Coping Behaviors:
• Give the client the opportunity to compare and
contrast ways in which he or she has coped with
significant loss in the past, and helping him or her to
review strengths and renew a sense of personal
power.
• Encourage the client to care for himself or herself.
The nurse can offer food without pressuring the client
to eat.
• Encourage the client to go back to a routine of work
or focusing on other members of the family may
provide that respite.
• Encourage volunteer activities—volunteering at a
hospice or botanical garden, taking part in church
activities, or speaking to bereavement education
groups
Points to ponder:
• Communication and interpersonal skills are tools of
the effective nurse, just like a stethoscope, scissors,
and gloves.
• A welcoming smile and eye contact from the client
during intimate conversations usually indicate the
nurse’s trustworthiness.
• In addition to previously mentioned skills, these tools
include the following:
➢ Using simple nonjudgmental statements to
acknowledge loss: “I want you to know I’m
thinking of you.”
➢ Referring to a loved one or object of loss by
name (if acceptable in the client’s culture).
➢ Remembering words are not always
necessary; a light touch on the elbow,
shoulder, or hand or just being there
indicates caring.
➢ Respecting the client’s unique process of
grieving.
➢ Respecting the client’s personal beliefs.
➢ Being honest, dependable, consistent, and
worthy of the client’s trust.
• Explore client’s perception and meaning of his or her
loss
• Allow adaptive denial
• Encourage or assist client to reach out for and accept
support
• Encourage client to examine patterns of coping in
part and present situation of loss
• Encourage client to review personal strengths and
personal power
• Encourage client to care for himself or herself
• Offer client food without pressure to eat
• Use effective communication
➢ Offer presence and give broad openings
➢ Use open-ended questions
➢ Encourage description
➢ Share observations
➢ Use reflection
➢ Seek validation of perceptions
➢ Provide information
➢ Voice doubt
➢ Use focusing
➢ Attempt to translate into feelings or
verbalize the implied
• Establish rapport and maintain interpersonal skills
such as
➢ Attentive presence
➢ Respect for client’s unique grieving process
➢ Respect for client’s personal beliefs
➢ Being trustworthy: honest, dependable,
consistent
➢ Periodic self-inventory of attitudes and
issues related to loss
EVALUATIONS
• Evaluation of progress depends on the goals
established for the client.
• A review of the tasks and phases of grieving can be
useful in making a statement about the client’s status
at any given moment.
• The nurse may say the client is still experiencing
denial or outcry emotions. Or that the client is
showing signs of reorganization, recovery, or
healing.
6 l Transcripted for educational by: Khelzy A. De Gracia, SN
Note: For educational purpose only. No copyright infringement intended.
Points to Consider When Working with Clients with Grief
and Loss
Taking a self-awareness inventory means periodic reflection
on questions, such as the following:
• What are the losses in my life, and how do they affect
me?
• Am I currently grieving for a significant loss?
• How does my loss affect my ability to be present to
my client?
• Who is there for me as I grieve?
• How am I coping with my loss?
• Is the pain of my personal grief spilling over as I listen
and watch for cues of the client’s grieving?
• Am I making assumptions about the client’s
experience based on my own process?
• Can I keep appropriate nurse–client boundaries as I
attend to the client’s needs?
• Do I have the strength to be present and to facilitate
the client’s grief?
• What does my supervisor or a trusted colleague
observe about my current ability to support a client in
the grief process?
• Crisis theory can be used to help the nurse working
with a grieving client. Adequate perception, adequate
support, and adequate coping are critical factors.
• Effective communication skills are the key to
successful assessment and interventions.
• Interventions focused on the perception of loss
include exploring the meaning of the loss and
allowing adaptive denial, which is the process of
gradually adjusting to the reality of a loss.
• Being there to help the client while assisting him or
her to seek other sources of support is an essential
intervention.
• Encouraging the client to care for himself or herself
promotes adequate coping.
• To earn the client’s trust, the nurse must examine his
or her own attitudes about loss and periodically take
a self-awareness inventory.

SUMMARY
• Grief refers to the subjective emotions and affect that
are normal responses to the experience of loss.
• Grieving is the process by which a person
experiences grief.
• Types of losses can be identified as unfulfilled or
unmet human needs. Maslow’s hierarchy of human
needs is a useful model to understand loss as it
relates to unfulfilled human needs.
• Grief work is one of life’s most difficult challenges.
The challenge of integrating a loss requires all that
the person can give of mind, body, and spirit.
• Because the nurse constantly interacts with clients at
various points on the health–illness continuum, he or
she must understand loss and the process of
grieving.
• The process of grieving has been described by many
theorists including Kubler-Ross, Bowlby, Engel, and
Horowitz.
• Dimensions of human response include cognitive,
emotional, spiritual, behavioral, and physiologic.
People may be experiencing more than one phase of
the grieving process at a time.
• Culturally bound reactions to loss are often lost in the
acculturation to dominant societal norms. Both
universal and culture-specific rituals facilitate
grieving.
• Disenfranchised grief often involves deaths,
mourners, or situations that are not socially
supported or sanctioned, or carry a stigma for the
mourners.
• Complicated grieving is a response that lies outside
the norm. The person may be void of emotion, grieve
for a prolonged period, or express feelings that seem
out of proportion.
• Low self-esteem, distrust of others, a psychiatric
disorder, previous suicide threats or attempts, and
absent or unhelpful family members increase the risk
of complicated grieving.
• Situations considered risk factors for complicated
grief in those already vulnerable include death of a
spouse or child, a sudden unexpected death, and
murder. During assessment, the nurse observes and
listens for cues in what the person thinks and feels
and how he or she behaves, and then uses these
relevant data to guide the client in the grieving
process.

7 l Transcripted for educational by: Khelzy A. De Gracia, SN

Note: For educational purpose only. No copyright infringement intended.