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Course: Fundamental Nursing

Topic: Nurse’s Role in Grief and Loss

The Nurses International Community

Contact info: info@nursesinternational.org

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Module Goals

Learners will be able to:

Define grief, loss, and bereavement.
Describe types and stages of grief.
Describe the nurse’s role in supporting clients with grief and loss.

Contact info: info@nursesinternational.org

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What is Grief?

Emotional response to a loss.

Defined as the individualized and personalized feelings and responses that an individual makes to real, perceived, or anticipated loss.

May include anger, frustration, loneliness, sadness, guilt, regret, and peace.

Affects survivors physically, psychologically, socially, and spiritually.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Loss and Mourning

Loss is the absence of a possession or future possession with the response of grief and the expression of mourning.

Associated with loss of health, changes in relationships/roles, and eventually the loss of life.

Mourning: An outward, social expression of loss

Greatly influenced by cultural norms, traditions, rituals, practices

dictates how long one mourns and how mourners “should” act.

Individual’s personality and previous life experiences also affect expression of loss.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Types of Grief

Anticipatory grief
Acute grief
Normal grief
Disenfranchised grief
Complicated grief

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Anticipatory Grief

Defined as grief before a loss, associated with diagnosis of an acute, chronic, and/or terminal illness experienced by the client, family, or caregivers.

Actual or fear of potential loss of health, independence, body part, financial stability, choice, or mental function.

Can be felt by both client and families, may proceed till death.
Often anticipates the loss of independence, function, or comfort, which can cause significant pain and anxiety if not given the proper support.
Anticipatory grief has been shown to help cushion a person’s bereavement reaction.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Acute Grief

Begins immediately after the death of a loved one and includes the separation response and response to stress.

During this period bereaved person may be:

Confused and/or uncertain about their identity or social role.
Disengaged from their usual activities and experience disbelief and shock that their loved one is gone.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Normal Grief

Includes the common feelings, behaviors, and reactions to loss.

Normal grief reactions to loss include signs/symptoms like:

Physical: hollowness in the stomach, tightness in the chest, weakness, heart palpitations, sensitivity to noise, breathlessness, tension, lack of energy, and dry mouth.

Emotional: numbness, sadness, fear, anger, shame, loneliness, relief, emancipation, yearning, anxiety, guilt, self-reproach, helplessness, and abandonment.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Normal Grief

Cognitive: a state of depersonalization, confusion, inability to concentrate, dreams of the deceased, idealization of the deceased, or a sense of presence of the deceased.

Behavioral: impaired work performance, crying, withdrawal, overreactivity, changed relationships, or avoidance of reminders of the deceased.

May proceed to months or years, depending on the loss.

No one ever truly gets over the loss, but there is an eventual reconnection with the world of the living.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Disenfranchised Grief

Grief over any loss that is not validated or recognized.

Those affected by this type of grief do not feel the freedom to openly acknowledge their grief.

Examples:

Loss of loved ones to stigmatized illnesses or events, such as AIDS
Loss pregnancies
Loss of a previously severed relationship or divorce

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Complicated Grief

Grief where feelings of loss are debilitating and do not improve after a long amount of time passes¹.

Painful emotions are so consuming that the individual has trouble recovering from the loss to resume their life.

Normal grief move toward growth and healing, whereas complicated grief will likely worsen.

Complicated grief may require professional assistance depending on its severity.

Oates & Maani-Fogelman, 2021

Contact info: info@nursesinternational.org

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Complicated Grief

Risk factors for developing complicated grief include:

Sudden or traumatic death
Suicide
Homicide
Dependent relationship with the deceased
Chronic illness
Death of a child
Multiple losses
Unresolved grief from prior losses
Concurrent stressors
Witnessing a difficult dying process such as pain and suffering
Lack of support systems
Lack of a faith system

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Types of Complicated Grief

Chronic Grief: Normal grief reactions that do not subside and continue over very long periods of time.
Delayed Grief: Normal grief reactions that are suppressed or postponed by the survivor consciously or unconsciously to avoid the pain of the loss.
Exaggerated Grief: An intense reaction to grief that may include nightmares, delinquent behaviors, phobias, and thoughts of suicide.
Masked Grief: Grief that occurs when the survivor is not aware of behaviors that interfere with normal functioning as a result of the loss¹ Example: Cancel lunch with friends to go to the cemetery daily to visit loved one’s grave.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Complicated Grief

Signs/symptoms of complicated grief:

Intense sorrow, rumination over the loss
Inability to focus on anything other than the loss itself
Intense and persistent longing or pining for the deceased
Difficulty accepting the death
Numbness or detachment
Bitterness about loss
Feelings that life holds no meaning or purpose
Lack of trust in others
Inability to enjoy life or even remember any positive experiences of a loved one
Have trouble carrying out normal routines

Oates & Maani-Fogelman, 2021

Contact info: info@nursesinternational.org

Glossary:

Rumination:

‘According to the online Merriam-Webster dictionary, the word “rumination” is defined as an “obsessive or abnormal reflection upon an idea or deliberation over a choice…

With regard to a clinical definition, Nolen-Hoeksema et al3 describe rumination as a mode of responding to distress—one that entails repetitively and passively focusing on the distress as well as its possible causes and consequences. These authors emphasize that rumination represents the process of thinking perseveratively about one’s feelings and problems, rather than rumination being solely related to thought content. Lynn et al4 describe rumination as “repetitive and passive thinking…that dominates attention.”4 Ito et al5 describe rumination as a tendency to continue to think about something bad, harmful, or unhopeful for a long time.’

(Sansone & Sansone, 2012)

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Stages of Grief

Swiss psychiatrist Elizabeth Kubler-Ross identified five stages of grief process¹:

Denial
Anger
Bargaining
Depression
Acceptance

These stages of grief also occur due to significant life changes such as divorce, loss of friendships, loss of a job, or diagnosis with a chronic or terminal illness.

American Nurses Association, 2015,

as cited in Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Denial

Occurs when the individual refuses to acknowledge the loss or pretends it isn’t happening.

Example: “This can’t be happening.’

Is self-protective as an individual attempts to numb overwhelming emotions as they process the information.

Commonly experienced during traumatic or sudden loss or if unexpected life-changing information or events occur.

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Anger

Anger often masks pain and sadness.
Can be projected towards others, internalized to self, or directed to individual who was lost.
Nurses should seek to recognize that:

These anger and emotion are not a personal attack.
Is manifestation of the challenging emotions as part of the grief process.

Nursing management:

Provide supportive presence, allow time to vent anger/frustration.
Allow a safe place to verbalize frustration, sorrow, and anger.

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Bargaining

Client/families make an attempt to regain control of the loss.
Look to find ways to change or negotiate the outcome by making a deal.
May try to make a deal with God or their higher power to take away their pain or to change their reality by making promises to do better or give more of themselves if only the circumstances were different.

Example: “If only we had gone to the doctor sooner, we could have stopped this.”

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Depression

Can occur with intense sadness over the loss of loved one or the situation.
Signs/symptoms may include:

Loss of interest in activities, or relationships that previous brought one satisfaction.
Irritability, sleeplessness, loss of focus.
Extreme fatigue and loss of energy.
Simple tasks of daily living can feel overwhelming.

Can be associated with ineffective coping behaviours like use of alcohol or drugs to mask numb feelings.

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Acceptance

Is the acknowledgement of one’s capabilities in coping with the grief experience.
It does not mean absence of sadness.
At this stage of grief an individual:

Understands the loss
Knows it will be hard
Acknowledge the new reality

Individuals begins to:

Re-engage with others
find comfort in new routines
Even experience happiness with life activities

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Grief Tasks

Tasks that one must accomplish in grieving process:

Notification and Shock: Occurs when a person first learns of the loss and experiences feelings of numbness or shock; First task is to acknowledge the reality of the loss by assessing and recognizing it.

Experiencing loss: Second task is to experience loss emotionally and cognitively; work through pain by reacting to, expressing, and experiencing pain of separation and grief.

Reintegration: Third task is reorganization and restructuring of family systems and relationships by adjusting to the environment without the deceased.

Lowey, 2015,

as cited in Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Possible Behaviors in Grieving People

Socially withdrawing
Difficulty thinking, concentrating, restlessness, anxiety, tired, weak
Loss of appetite, loses weight, appears sad, feelings of depression, trouble sleeping.
Dreams of deceased, preoccupied with death, searches for reasons for loss.
Dwells on mistakes, feels guilty, alone.
Expresses anger or envy of others with their loved ones.

American Cancer Society, 2019

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

A terminally ill client is being cared for by the nurse and the client’s family. The nursing implications for the client and the family include which of the following? (Select all that apply)

Assist the client and family in understanding grief and acceptance of impending death
Provide a referral for spiritual assistance depending on the clients beliefs
Tell the client and family not to worry because everything will be okay
Provide active listening so the client and families needs can be identified

Contact info: info@nursesinternational.org

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Grieving Process

Grief process is not orderly and predictable.
Emotional oscillation is normal and expected.
There are times when the person experiencing the loss feels in control and accepting, and there are other times when the loss feels unbearable and they feel out of control.
It is not uncommon for the grief to last a year or longer.
Even though the pain loses intensity it is not unusual for someone to be emotionally focused on the relationship with the deceased for years.

Ernstemeyer & Christman, 2021

American Cancer Society, 2019

Contact info: info@nursesinternational.org

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Bereavement

It is grief (the inner feelings) and mourning (the outward reactions) after a loved one has died.
Bereavement period is the time it takes for the mourner to feel the pain of the loss, mourn, grieve, and adjust to the world without the presence of the deceased.
Can take a physical toll on a survivor

Associated with an increased risk of myocardial infarction and cardiomyopathy for survivors.
Widows and widowers have an increased chance of dying after their spouses die.

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Nursing Interventions in Bereavement

Understand client’s feelings are normal
Establish a trusting therapeutic relationship
Encourage the client to verbalize feelings
Listen and be present

More important than saying the “right words”.

Provide empathetic nonverbal communication.

Helpful to simply encourage silence.

Assess and facilitate spirituality where appropriate.
Encourage and assist client and family to identify strengths and effective coping strategies.

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Therapeutic Communication in Bereavement

Avoid statements like, “I know/can imagine/understand how you feel.” Even if you have been through a similar situation, you don’t know how the survivor feels. Instead say, “I’m sorry you have to go through this…” or “I know this is hard…”

Don’t minimize the individual’s grief reaction with a statement like, “You should be over this by now.” Instead, say, “This process takes time, so don’t feel as if you need to rush through it.”

Avoid statements that minimize the significance of the loss, such as, “At least you had a good life with them.” Instead, focus on exploring their feelings related to the loss, such as, “Tell me what your relationship was like.”

Ernstemeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Suggestions for Coping with Loss

Think of strategies used to deal with difficult situations in the past.
Allow oneself to feel the pain of impending loss or loss.
Be patient and try to understand that grief is normal.
Talk with others about the sadness, and explain need for someone to just listen, not solve the problem.
Find creative outlets such as journaling.
Forgive oneself.

American Society of Clinical Oncology, 2018

Contact info: info@nursesinternational.org

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Support Networks

Support network or groups can:

Help clients and families feel better and know they are not alone.
Provide an opportunity to talk and work through feelings.
Help deal with practical problems such as issues that arise with work or school.
Assists in coping with treatment and side effects of treatment.

Nurses should be aware of resources and support centers in the community that help with grief and loss, bereavement.

Provide information on these resources to client and family.

National Cancer Institute, 2019

Contact info: info@nursesinternational.org

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Support Networks/Groups

Examples from Australia:

Examples of International Support Networks

Contact info: info@nursesinternational.org

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What are some of the support networks/groups available in your country or local community that assist clients and families with grief and loss?

As a nurse, one must be aware of national/provincial/local resources to help client and families!

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

A terminally ill client expresses fear of not being allowed in heaven upon death. How should the nurse respond?

“You shouldn’t worry about that. I am sure God understands.”
“What do you usually do when you are fearful?”
“I will call a pastor to speak with you.”
“Please explain what is making you feel that way.”

Contact info: info@nursesinternational.org

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Red Flags

Overwhelming depression.
Inability to talk with others.
Self-mutilation without meaning to cause death.
Suicidal ideations and developing a plan might be accepted in some cultures or areas.
Life circumstances and overwhelming stressor may precede or increase the risk of suicide.
Effects of suicide on loved ones can be devastating and cause conflicting emotions.

MedicineNet, 2007

Contact info: info@nursesinternational.org

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Cultural Considerations

Cultural perspectives can be unique as grief is shaped by one’s society and culture.
Turkish cultural perspectives seek the lesson God might be teaching them through their illness and Ethiopians may not practice preventative health care or seek out care from Westerners.
Christianity believes in heaven and hell, Judaism encourages the reciting of the confessional and Islams belief is 1 God and the prophet Muhammad.
Romani believe in the evil eye and discussions of cancer cause death and Hmong believe Spiritual illness cause cancer and balance can be restored with hot/cold remedies.

Honan et al., 2018

Ignatavicius et al., 2020

Contact info: info@nursesinternational.org

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Additional Cultural Considerations

Although cultures are different, personal experiences among cultures are similar.
Different cultures have different mourning ceremonies and grief may be interdependent with unfinished business.
Demonstrate respect regardless of the cultural beliefs.
Ask questions about final arrangements.
What does the family or client feel happens after death and what roles does each family member play?
A culture may respond the loss or death with grief or celebration.

MedicineNet, 2007

Contact info: info@nursesinternational.org

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References

American Cancer Society. (2019, May 10). Grief and bereavement. https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/grieving-process.html

American Society of Clinical Oncology. (2018, March). Coping with Grief. Cancer.Net. Retrieved on September 27, 2021, from https://www.cancer.net/coping-with-cancer/managing-emotions/grief-and-loss/coping-with-grief

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/open/download?type=pdf

Contact info: info@nursesinternational.org

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References

Honan, L., Bautista, C., & Eposito, C., (2018). Focus on Adult Health Medical-Surgical Nursing 2nd ed. Philadelphia, PA. Lippincott, Williams and Wilkins, Wolters Kluwer.

Ignatavicius, D.D., Workman, M. L., Rebar, C. R., & Heimgartner, N.M. (2020). Medical-Surgical Nursing E-Book: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

National Cancer Institute (2019). Cancer Support Groups. Retrieved from: https://www.cancer.gov/about-cancer/coping/adjusting-to-cancer/support-groups

Oates, J.R., Maani-Fogelman, P.A. (2021, August 11). Nursing Grief and Loss. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518989/

Contact info: info@nursesinternational.org

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