Grief

Subjective emotions and affect; normal response to loss Grieving/bereavement: process by which person

experiences grief; content, process Anticipatory grieving: persons facing imminent loss begins to deal with very real possibility of loss or death in near future Mourning: outward expression of grief, including rituals

Types of Losses
Physiologic loss
Safety loss Loss of security, sense of belonging Loss of self-esteem Loss related to self-actualization

Theories of Grieving
Kubler-Rosss five stages of grieving (Table 12.1) Denial Anger Bargaining Depression Acceptance

Theories of Grieving (contd)

Bowlbys phases of grieving Numbness, denial of loss Emotional yearning for lost loved one; protest over permanence of loss Cognitive disorganization, emotional despair; difficulty functioning Reorganization, reintegration

Theories of Grieving (contd)

Engels five stages of Horowitzs four stages of

grieving
Shock and disbelief Developing awareness Restitution Resolution of loss Recovery

loss and adaptation

Outcry Denial and intrusion Working through Completion

Question
Tell whether the following statement is true or false:
The first stage of grieving according to Kubler-Ross is

anger.

Answer
False
According to Kubler-Ross, the first stage of grieving is

denial, which is followed by anger.

Tasks of the Grieving

Randos six Rs Recognize React Recollect and reexperience Relinquish Readjust Reinvest Wordens tasks Accept reality of loss Work through pain of grief Adjust to changed environment due to loss Emotionally relocate loss and move on

Dimensions of Grieving
Cognitive responses Questioning, trying to make sense of loss Attempting to keep lost one present Emotional responses (anger, sadness, anxiety)

Spiritual responses
Behavioral responses Physiologic responses

Cultural Considerations
Grief by all for lost loved ones Rituals, habits surrounding death highly variable

Grieving, mourning, integration of loss culturally defined

Need for nurses to be sensitive to cultural

differences/rituals Cultural rituals with roots in major religions

Cultural Considerations (contd)

African Americans: deceased viewed in church before

burial in cemetery; public prayers, black clothing, decreased social activities Muslim Americans: five steps of burial procedure including washing, dressing, and positioning of body
First step: traditional washing by Muslim of same gender

Cultural Considerations (contd)

Haitian Americans: Vodun (voodoo)
Chinese Americans: strict norms for announcing

death, preparing body, arranging funeral and burial, mourning after burial
Bowls of food on table for spirit for 1 year after death

Cultural Considerations (contd)

Japanese Americans: death as life passage; bathing

with warm water and dressing in white kimono after purification rites Filipino Americans: black clothing or armbands; wreaths on casket; black cloth on home of deceased

Cultural Considerations (contd)

Vietnamese Americans: bathing deceased and

dressing in black clothing; rice in mouth and money; display of body for viewing in home before burial

Question
Which of the following cultures most likely would

practice washing of the deceased body by a member of the same gender? A. African American B. Muslim American C. Haitian American D. Chinese American

Answer
B. Muslim American
Muslim Americans adhere to five steps of the burial

procedure, including washing, dressing, and positioning of the body. The first step is traditional washing of the body by a Muslim of the same gender.
This is not applicable to African Americans, Haitian

Americans, or Chinese Americans.

Cultural Considerations (contd)

Hispanic Americans: novena (9-day prayers) and

rosary; luto Native Americans: tribal medicine man or priestly healer; baptism ceremonies; end of mourning noted with ceremony at burial ground with grave covered with blanket or cloth later given to tribe member

Cultural Considerations (contd)

Orthodox Jewish Americans: relative staying with

dying person; body covered with sheet; eyes closed; burial within 24 hours of death unless Sabbath; Shivah

Cultural Considerations (contd)

Nurses role Encouraging clients to discover, use effective and meaningful grieving behaviors Praying Staying with body Performance of rituals Memorials, public services

Disenfranchised Grief
Grief over 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

Disenfranchised Grief (contd)

Grief process more complex due to absence of usual

support for grieving, healing Experienced by nurses when need to grieve not recognized

Complicated Grieving
Person devoid of emotion; grieving for prolonged

periods; expressions of grief seems disproportionate to event

Complicated Grieving (contd)

Characteristics of susceptibility Low self-esteem Low trust in others Previous psychiatric disorder Previous suicide threats or attempts Absent or unhelpful family members Ambivalent, dependent, insecure attachment to deceased person

Complicated Grieving (contd)

Risk factors leading to vulnerability Death of spouse or child Death of parent (particularly in early childhood or adolescence) Sudden, unexpected, untimely death Multiple deaths Death by suicide or murder Unique, varied experience (physical, emotional

reactions)

The Nursing Process: Assessment

All dimensions of human response (Box 12.1)
Three critical components Adequate perception regarding loss Adequate support while grieving for loss Adequate coping behaviors during process

The Nursing Process: Data Analysis and Planning

Possible nursing diagnoses Grieving Complicated grieving Outcome identification: client will Identify effects/meaning of his or her loss Seek adequate support/develop plan for coping/apply effective coping strategies Recognize negative effects of loss on life Seek or accept professional assistance if needed

The Nursing Process: Interventions

Exploring perception of loss Cognitive responses Adaptive denial Obtaining support Promoting coping behaviors (see Nursing Interventions

for Grief)
Reviewing strengths of past coping
Encouraging self-care Using communication, interpersonal skills

Question
Tell whether the following statement is true or false:
Nurses commonly experience complicated grief.

Answer
False
Although it is possible for anyone to experience

complicated grief, a nurse would be more likely to experience disenfranchised grief when his or her need to grieve is not recognized.

The Nursing Process: Evaluation

Review of tasks, phases of grieving
Demonstration of continuing denial or outcry Evidence of reorganization, recovery, healing

Self-Awareness Issues
Examining ones own experiences with grief, loss
Taking self-awareness inventory, reflecting on results Performing ongoing self-evaluation