Chapter 12

Grief and Loss

Grief refers to the subjective emotions and
affect that are a normal response to loss.
Grieving, also known as bereavement, is
the process of experiencing grief.
Anticipatory grief is facing an imminent
loss.
Mourning is the outward sign of grief.
Experiences of grief and
loss are essential and
normal in the course
of life; letting go,
relinquishing, and
moving on happen
as we grow and
develop.

Grief and loss are

uncomfortable.
Types of Losses

Losses may be planned, expected, or

sudden. Loss of a loved one is probably
the most devastating type of loss, but
there are many other types of losses:
• Physiologic (loss of limb, ability to
breathe)
• Safety (domestic violence,
posttraumatic stress disorder, breach of
confidentiality)
Types of Losses (cont’d)
• Security/sense of belonging
(relationship loss [death, divorce])
• Self-esteem (ability to work, children
leaving home)
• Self-actualization (loss of personal
goals, such as not going to college,
never becoming an artist or dancer)
The Grieving Process

Nurses must recognize the signs of grieving to

understand and support the client through
the grieving process.
The therapeutic relationship and therapeutic
communication skills are paramount when
assisting grieving clients. Using these skills,
nurses may promote the expression and
release of emotional as well as physical pain
during grieving.
Theories of the Grieving Process
Kubler-Ross’s stages of grieving:
• Denial (shock and disbelief)
• Anger (toward God, relatives, health care
providers)
• Bargaining (trying to get more time, prolonging
the inevitable loss)
• Depression (awareness of the loss becomes
acute)
• Acceptance (person comes to terms with
impending death or loss)
Theories of the Grieving Process (cont’d)
Bowlby’s phases of grieving:
• Numbness and denial of the loss
• Emotional yearning for lost loved one
and protesting permanence of loss
• Cognitive disorganization and
emotional despair
• Reorganizing and reintegrating sense
of self
Theories of the Grieving Process (cont’d)
John Harvey’s phases of grieving:
• Shock, outcry, and denial
• Intrusion of thoughts, distractions, and
obsessive reviewing of loss
• Confiding in others to emote and
cognitively restructure
Theories of the Grieving Process (cont’d)
Rodebaugh’s stages of grieving:
• Reeling
• Feelings
• Dealing
• Healing
There are many similarities among theorists
about grief. Not all clients follow
predictable steps or make steady progress.
Tasks of the Grieving Process

• Undoing psychosocial bonds to loved

one and eventually creating new ties
• Adding new roles, skills, and behaviors
• Pursuing a healthy lifestyle
• Integrating the loss into life
Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to make sense of the loss
– Attempting to keep the lost one present

• Emotional responses to grief

• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief
Cultural Considerations
All cultures grieve for lost loved ones,
but the rituals and habits surrounding
death vary among cultures, for
instance, how shock and sadness are
expressed, how long mourning should
last, and so forth. Many cultural
bereavement rituals have their roots in
a major religion.
Nurses should be sensitive to cultural
differences and ask how the mourners
can be assisted.
African Americans
• Typically view the body in church
before burial
• Hymns, poetry, eulogies common
• Mourning may be expressed by public
prayer, wearing black clothing, and
decreasing social activities for a few
weeks to several years
Muslim Americans
• Muslims do not permit cremation
• Important to follow the five steps of
the burial procedure
Haitian Americans
• May practice vodun or calling on spirits
to make peace
Chinese Americans
• Strict norms for announcing death,
preparing the body, arranging the
funeral and burial, mourning
• Burning incense and reading scripture
assist the spirit of the deceased on his
or her journey
Japanese Americans
• Japanese Americans who are
Buddhists view death as a life passage
• Bathing and purification rites are
performed
• Friends and family visit, bringing gifts
or money
• Prayers are said
• Incense is burned
Filipino Americans
• Often Catholic
• Wear armbands or black clothing
• Place wreaths on casket
• Drape a black banner on the
deceased’s home
• Ask for prayers and blessings for the
soul of the deceased
Vietnamese Americans
• Predominately Buddhist
• Deceased is bathed and dressed in
black clothes
• Rice and money may be sent with the
deceased on the journey to the afterlife
• Viewing the body before burial occurs
at home
Hispanic Americans
• Predominately Catholic
• Pray for the soul during a novena and
rosary
• Mourning may involve wearing black
and decreasing social activities
• A wake in the home may be held
Native Americans
• Variety of practices depending on religious
beliefs and practices of different tribes
• Death may be seen as a state of
unconditional love
• Many believe the deceased is going on
another journey
• Celebrations may include a ghost meal
• Mourners may be encouraged to be happy
for the person
Orthodox Jewish Americans
• Leaving a dying person alone is a
sign of disrespect
• Burial must occur within 24 hours
unless delayed by the Sabbath
• Body should be untouched until rites
can be performed by family, rabbi, or
Jewish undertaker
Nurse’s Role
The nurse must encourage clients to
discover and use effective and meaningful
grieving behaviors:
• Praying
• Staying with the body
• Performing rituals
• Attending memorials and public services
Disenfranchised Grief or
Complicated Grieving
Disenfranchised grief is grief over a loss that
is not or cannot be openly acknowledged,
mourned publicly, or supported socially:
• A relationship has no legitimacy
• The loss itself is not recognized
• The griever is not recognized

Complicated grieving is a response that lies

outside the norm of grieving in terms of
extended periods of grieving: responses that
seem out of proportion or responses that are
void of emotion
Disenfranchised Grief
People who are vulnerable to
disenfranchised grieving:
• Relationships that may be viewed as having no
legitimacy: lovers, friends, neighbors, foster
parents, colleagues, caregivers, same-sex
relationships, cohabitation without marriage, and
extramarital affairs
• Losses that may not be recognized: prenatal death,
abortion, relinquishing a child for adoption, death of
a pet, or other losses not involving death such as
job loss, separation, divorce, and children leaving
home
• Grievers who may not be recognized: older adults,
children, nurses
Complicated Grieving
People who are vulnerable to
complicated grieving include
those with:
• Low self-esteem
• Low trust in others
• A previous psychiatric disorder
• Previous suicide threats or attempts
• Absent or unhelpful family members
• An ambivalent, dependent, or insecure attachment
to the deceased person
Complicated Grieving (cont’d)
Experiences increasing the risk for
complicated grieving include:
• Death of a spouse or child
• Death of a parent (particularly in early
childhood or adolescence)
• Sudden, unexpected, and untimely death
• Multiple deaths
• Death by suicide or murder
Complicated Grieving as a Unique and
Varied Experience
• Physical reactions can include:
– Impaired immune system
– Increased adrenocortical activity
– Increased levels of serum prolactin and growth hormone
– Psychosomatic disorders
– Increased mortality from heart disease

• Emotional responses can include:

– Depression
– Anxiety or panic disorders
– Delayed or inhibited grief
– Chronic grief
Application of the Nursing Process
Assessment
• Does the client have adequate perception
regarding the loss?
– What does the client think and feel about the loss?
– How is the loss going to affect the client’s life?
– What information does the nurse need to clarify or share
with the client?

• Does the client have

adequate support?
• Does the client have
adequate coping
behaviors?
Application of the Nursing Process (cont’d)
Data Analysis and Planning
Possible nursing diagnoses:
• Grieving
• Anticipatory Grieving
• Dysfunctional Grieving
Application of the Nursing Process (cont’d)
Outcome Identification
Grieving
The client will:
• Identify the effects of his or her loss
• Seek adequate support
• Apply effective coping strategies while
expressing and assimilating all
dimensions of human response to loss
in his or her life
Application of the Nursing Process (cont’d)
Outcome Identification (cont’d)
Anticipatory Grieving
The client will:
• Identify the meaning of the expected loss
in his or her life
• Seek adequate support while expressing
grief
• Develop a plan for coping with the loss as it
becomes a reality
Application of the Nursing Process (cont’d)
Outcome Identification (cont’d)
Dysfunctional Grieving
The client will:
• Identify the meaning of his or her loss
• Recognize the negative effects of the
loss on his or her life
• Seek or accept professional assistance
to promote the grieving process
Application of the Nursing Process (cont’d)
Intervention
• Regarding perception of the loss
– Explore perception and meaning of the loss

• Regarding adequate support

– Help the client reach out and accept what others want to
give

• Regarding adequate coping behaviors

– Shift from an unconscious defense mechanism to
conscious coping
– Compare and contrast past coping
– Encourage the client to care for self
Application of the Nursing Process (cont’d)
Essential communication and interpersonal
skills to assist grieving:
• Use simple, nonjudgmental statements
• Refer to a loved one or object of loss by name (if
acceptable in the client’s culture)
• Appropriate use of touch indicates caring
• Respect the client’s unique process of grieving
• Respect the client’s personal beliefs
• Be honest, dependable, consistent, and worthy of the
client’s trust
• Offer a welcoming smile and eye contact
Application of the Nursing Process (cont’d)
Evaluation
Evaluation of progress is based on the
goals established for the client.
Make an evaluation of the client’s
status based on the theoretical tasks
and phases of grieving.
Self-Awareness Issues

• Examining one’s own experiences with

grief and loss
• Taking a self-awareness inventory and
reflecting on the results may be
helpful.