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Physiologic loss: Examples include amputation of limb, loss of adequate air exchange, or
decrease in pancreatic functioning etc.
Safety loss: Loss of safe environment is evident in domestic or public violence. A person may
perceive a breach of confidentiality in a professional relationship as a loss of psychological
safety secondary to broken trust of self and health care provider.
Loss of security and a sense of belonging: The loss of a loved one affects the need to love
and be loved. Loss accompanies changes in relationships, such as birth, marriage, divorce,
illness and death; as the meaning of a relationship changes, a person may lose role within the
family and group.
Loss of self esteem: Any change in how a person is valued at work or in a relationship can
threaten his or her self esteem needs. A change in self perception can challenge sense of self
worth. A loss of role function and the self-perception and worth tied to that role may
accompany the death of a loved one.
Loss related to self actualization: An external or internal crisis that blocks or inhibits striving
towards fulfillment may threaten personal goals and individual potentials. A change in goals or
direction will precipitate an inevitable period of grief. E.g.: having to give up plans to attend
graduate school or losing the hope of marriage and family.
GRIEF OR GRIEVING PROCESS
Grief is a multi-faceted response to loss. It includes the emotion numbness, disbelief, separation,
anxiety, despair, sadness, and loneliness that accompany the loss of someone or something loved.
Although conventionally focused on the emotional response to loss, it also has physical, cognitive,
behavioral, social, and philosophical dimensions. Common to human experience is the death of a
loved one, whether it be a friend, family, or other companion. While the terms are often used
interchangeably, bereavement often refers to the state of loss, and grief to the reaction to loss.
TYPES OF GRIEF
1. Normal grief: It is said to occur when a persons emotional and behavioral responses to a loss are
expected ones, according to the individuals experience, culture, social status, and relationship to
that which has been lost. Often the normal grief response to a loss can prove positive helping one
to mature and develop as a person.
Expected changes:
Functional Interpersonal
Physical Intrapersonal Spiritual beliefs
relationship
appetite ADL family roles mood the search for
sleeping Economic social status stress level understanding
pattern status social skills concentration the search for
energy level Productivity at thoughts of purpose and
sexual function work or school dying, death, meaning
blood pressure life, living. the need to ask
focus on health the' big
digestive
question'
process sense of self
general health identity
2. Anticipatory grief: It occurs before a death, usually at the time of diagnosis. A patient may
anticipate loss of good health, independence, and life itself. Family members, friends and
caregivers may grieve for the patients losses as well as their own.
This grief provides time to acknowledge that the patient is dying, to prepare for the death, to
adapt to changes, to tend to matters left unsettled and to resolve conflicts. When families are
prepared and support services are used before the death, healthy adaptation during bereavement is
more likely to occur.
There are risk in this type as family members may withdraw emotionally from the client too soon,
leaving the client with no emotional support as death approaches. Sometimes if the person nearing
death survives, family members may have difficulty reconnecting and may even be resentful that
the person has lived past life expectancy.
3. Complicated grief: When a person has difficulty progressing through the normal phases of
grieving it becomes complicated. This can threaten a persons relationship with others. It includes
the following types.
Chronic grief: Active acute mourning that is characterized by normal grief reaction that do
not subsides and continue over very long period of time. It is highlighted by bitterness and
idealization of the dead. It is more likely to occur when the relationship between the
bereaved and the deceased had been extremely close, ambivalent or dependent and when
social supports are lacking and friends and relatives are not available to share the sorrow
over the extended period of time needed for most mourners.
Delayed grief: characterized by normal grief reactions that are suppressed or postponed
and the survivor consciously or unconsciously avoids the pain of the loss. Active grieving
is held back only to resurface later usually in response to a trivial loss or upset. For e.g.: a
wife may only bereave a few weeks after the death of her spouse, only to become hysterical
and sad a year later when she attends a family gathering. This extreme sadness is a delayed
response to death of her husband.
Exaggerated grief: Persons become overwhelmed by the grief, and they cannot function.
This may be reflected in the form of severe phobias or self destructive behavior such as
alcoholism, substance abuse or suicide.
Masked grief: survivors are not aware that behaviors that interfere with normal functioning
are a result of their loss. For e.g.: a person who has lost a pet may develop alterations in
sleeping or eating patterns.
4. Disenfranchised grief: Persons experience grief when a loss is experienced and cannot be openly
acknowledged, socially sanctioned, or publically shared (ELNEC, 2000). An e.g.: includes the
loss of partner from HIV OR AIDS, children experiencing the death of a step-parent, or the
mother whose child dies in utero or at birth.
Denial Refuses to believe that loss is Verbally support client but do not reinforce
happening. denial.
Is unready to deal with practical Examine your own behavior to ensure that
problems, such as prosthesis after loss of you do not share in clients denial.
leg.
May assume artificial cheerfulness to
prolong denial.
Anger Client or family may direct anger at Help clients understand that anger is normal
nurse or staff about matters that response to feelings of loss and
normally would not bother them. powerlessness.
Avoid retaliation or withdrawal; do not take
anger personally.
Deal with needs underlying any angry
reaction.
Provide structure and continuity to promote
feelings of security.
Allow clients as much control over their
life.
Bargaining Seeks to bargain to avoid loss. May Listen attentively, and encourage clients to
express feelings of guilt or fear of talk to relieve guilt and irrational fear.
punishment for past sins, real or If appropriate, offer spiritual support.
imagined.
Depression Grieves over what has happened and Allow clients to express sadness.
what cannot be. Communicate nonverbally by sitting quietly
May talk freely or may withdraw. without expected conversation.
Acceptance Comes to terms with loss. Help family and friends understand clients
May have decreased interest in decreased need to socialize.
surroundings and support people. Encourage client to participate as much as
May wish to begin making plans (e.g., possible in the treatment program.
will, prosthesis etc)
When loss occurs within the system, the impact is experienced as acute grief. The systems
equilibrium is in chaos, and is seen as a functional disruption i.e. the system cant perform its usual
activities; either the person or the members are in a state of disequilibrium. The family or individual
then searches for meaning why this happen to them. The family then may become active in
informing others. It may involve engaging emotions that may have been previously withheld or
subdued. The expression of emotion can release energy that can be seen to recognize the family
structure. Someone else steps up to perform the role of dead person e.g. elder son in the fathers role.
Finally if the system is to survive it must redefine itself by reframing its memories i.e. families
accept the portraits and reunions are still possible, just different from how they were before loss.
reframin
g
impact
memorie
s
functiona
reorganis
l
ing
disruptio
structure
n
engaging informin
emotions g others
Toddlers are unable to understand loss or death, but they feel great anxiety over loss of objects
and separation from parents.
School age children experience grief over the loss of a body part or function.
Middle age adults usually began to reexamine life and are sensitive to their own physical
changes.
Malkinson and BarTur (1999) older adults often express anticipatory grief because of aging
and the possible loss of self care abilities. They are at increased risk of negative outcomes
related to grief. Lund (1989) found that older adults are often resilient in responding to grief
despite it being a highly stressful process.
Psychosocial perspective of loss and grief: The valuing of individuals is a unique, learned response
of a specific culture and society. Age, gender, status, race, spirituality, religious beliefs, intellect,
achievement, self expression and cultural opportunities are the basis for an individual to define and
qualify the definition of life and death. An individuals expression of grief evolves as the person
matures. Personal experiences shape the coping mechanism that the individual use to cope with
stressors. When older coping mechanisms are unsuccessful newer ones are attempted. Professional
assistance is often required to help the client and family understand and deal realistically with losses.
Socioeconomic status: It influences a persons ability to obtain options and use support mechanism
when coping with loss. Generally a person feels greater burden with loss when there is a lack of
financial, educational or occupational resources. For e.g. a client with limited financial resources may
not be able to buy necessary medications to a newly diagnosed disease.
Personal relationships: When loss involves a loved one, the quality and meaning of a relationship
are critical in understanding a persons grief experience. It has been said that to lose your parents is to
lose your past; to lose the spouse is to lose your present and to lose a child is to lose your future.
When a relationship between two individuals has been very close and well connected, it can be very
difficult for the one left behind to cope. When clients do not receive supporting understanding and
compassion from others, they become unable to handle grief and look to the future.
Nature of loss: The ability to resolve grief depends on the meaning of loss and the situation
surrounding the loss. The visibility of loss influences the support a person receives. For e.g. loss of
ones house in floods brings support from the community whereas a private loss of an important
possession may bring less support. The suddenness of a loss can often cause slower resolution from
grief. For e.g.: a sudden unexpected death in family is more difficult to accept compared to a one
following a long term chronic illness.
Culture and ethnicity: Interpretation of loss and the expression of grief arise from cultural
background and family practices. Culture affects how client and their support systems or families
respond to loss. For e.g. in the western hemisphere the grieving process is usually personal and
people show restrained emotions, whereas in eastern nations like India, China etc wailing and
physical demonstration of grief is seen. Nurses must be able to support and guide clients and families
in a culturally informed and acceptable manner. Research has shown that ethnicity is strongly related
to attitudes towards life sustaining treatment during terminal illness.
Spiritual beliefs: Individuals spirituality significantly influences their ability to cope with loss. Loss
can sometimes cause internal conflicts about spiritual values and the meaning of life. Clients who
have a strong interconnectedness with a higher power are often very resilient and able to face death
with relatively minimum discomfort.
DIMENSIONS AND SYMPTOMS OF GRIEVING CLIENT
o Cognitive Responses To Grief: The pain that accompanies grieving results from a
disturbance in the persons beliefs. The loss disrupts, if not shatters, basic assumptions about
lifes meaning and purpose.
Questioning and trying to make sense of loss: the grieving person needs to make sense of
the loss. The loss challenges old assumptions about life. For e.g. when a loved one dies
prematurely, the grieving person often questions the belief that life is fair. The nurse might
hear questions like why did such a young person have to die? Questioning may help the person
accept the reality of why someone died. It may result in realizing that loss and death are
realities that everyone must face one day.
Attempting to keep the lost one present: Belief in an afterlife and the idea that the lost one
has become a personal guide are cognitive responses that serve to keep the lost one present.
o Emotional responses to grief: Anger, sadness, and anxiety are the predominant emotional
responses to loss. The grieving person may direct anger and resentment towards the deceased
and his health practices, family members or health care providers. 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.
Research study: A study to assess the 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.
o Spiritual responses to grief: The deeply embedded personal values that give meaning and
purpose to life and the belief systems that sustain them are the central components of
spirituality and the spiritual response to grief. During loss, it is within the spiritual dimension
of human existence that a person may be lost comforted, challenged or devastated. The
grieving person may become disillusioned and angry with God. The anguish of abandonment,
loss of hope or loss of meaning can cause deep spiritual suffering. Ministering to the spiritual
needs of those grieving is an essential part of nursing care. Nurses can promote a sense of
wellbeing by providing opportunities for clients to share their sufferings and assists in the
psychological and spiritual transformation that can evolve through grieving.
o Behavioral responses to grief: By recognizing behaviors common to grieving, the nurse can
provide supportive guidance for the clients journey of emotionally and cognitively rough
terrain. The symptoms include:
Functioning automatically.
Tearful sobbing ; uncontrollable crying
Great restlessness; searching behaviors
Irritability and hostility
Seeking and avoiding places and activities with the 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 of reorganization.
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Stuart GW, Lararia MT. Principles and practice of psychiatric nursing. 8th edition. Missouri:
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Ebersole P, Hess P, Touhy TA, Jett K, Luggen AS.Towards healthy aging. 7th edition. Missouri:
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Townsend MC. Essentials of Psychiatric/ Mental health Nursing. Philadelphia: Lippincott;2007
Egan KA, Arnold LR. Grief and Bereavement care. American journal of nursing. September
103(9).2003
Clements PT. Grief-promoting adaptive coping Journal of psychosocial nursing. July 41(7). 2003
Swan P. Grief and health: the Indigenous legacy. Grief Matters 1998; 1(2):911.
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2003
Costello J. The emotional cost of palliative care. European Journal of Palliative Care. 1996; 3(4)
http://www.grief.net/Articles/Myth%20of%20Stages.pdf
http://psy.psychiatryonline.org/cgi/content
http://depression.about.com/od/grief/a/griefdepression.htm