Chapter 10:
Grief and Loss
Grief
Subjective emotions and affect; normal response to loss
Grieving/bereavement: process by which person
experiences grief
– Content
– Process
Anticipatory grieving: persons facing an imminent loss
begin to deal with possibility of loss or death in near
future
Mourning: outward expression of grief, including rituals
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Types of Losses
Physiological loss
Safety loss
Loss of security and a sense of belonging
Loss of self-esteem
Loss related to self-actualization
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Theories of Grieving #1 (See Table 10.1)
Kübler-Ross’s five stages of grieving
– Denial
– Anger
– Bargaining
– Depression
– Acceptance
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Theories of Grieving #2
Bowlby’s phases of grieving
– Numbness and denial of loss
– Emotional yearning for the lost loved one and
protesting permanence of loss
– Cognitive disorganization and emotional despair with
difficulty functioning
– Reorganization and reintegration
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Theories of Grieving #3
Engel’s stages of grieving
– Shock and disbelief
– Developing awareness
– Restitution
– Resolution of the loss
– Recovery
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Theories of Grieving #4
Horowitz’s stages of loss and adaptation
– Outcry
– Denial and intrusion
– Working through
– Completion
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1. Question #1
Is the following statement true or false?
The first stage of grieving, according to Kübler-Ross, is
anger.
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1. Answer to Question #1
False
Rationale: According to Kübler-Ross, the first stage of
grieving is denial, which is followed by anger.
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Tasks of Grieving
Rando’s “six Rs” Worden’s tasks
o Recognize o Accept reality of the
o React loss
o Recollect and o Work through pain of
reexperience grief
o Relinquish o Adjust to changed
o Readjust environment due to
loss
o Reinvest
o Emotionally relocate
loss and move on
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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
Physiological responses
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Cultural Considerations #1
Acculturation
– Funeral directors may discourage specific rights of
passage.
Cultural rituals with roots in major religions
In the United States, there are various mourning rituals
and practices.
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Cultural Considerations #2
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 the body
– First step involves traditional washing of the body by
a Muslim of the same gender.
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Cultural Considerations #3
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
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Cultural Considerations #4
Japanese Americans: death as life passage; bathe the
deceased with warm water; dress body in white kimono
after purification rites
Filipino Americans: black clothing or armbands; wreaths
on casket; black cloth on home of deceased
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Cultural Considerations #5
Vietnamese Americans: bathing deceased and dressing in
black clothing; rice in mouth; place money with
deceased; display of body for viewing in home before
burial; music played to warn deceased of friends’ arrival
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Cultural Considerations #6
Hispanic Americans: novena (9-day devotion) and
rosary; wear black or black and white; behave in
subdued manner
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
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Cultural Considerations #7
Orthodox Jewish Americans: relative staying with dying
person; body covered with sheet; eyes closed; burial
within 24 hours of death unless delayed by Sabbath;
practice of sitting Shiva
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2. Question #2
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
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2. Answer to Question #2
B. Muslim American
Rationale: 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.
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Cultural Considerations #8
Nurse’s role
– Individualize care
– Encourage patients to discover and use effective and
meaningful grieving behaviors
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Disenfranchised Grief #1
Grief over loss that is not or cannot be openly
acknowledged, mourned publicly, or supported socially:
– A relationship that has no legitimacy
– The loss itself is not recognized.
– The griever is not recognized.
– The loss involves social stigma.
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Disenfranchised Grief #2
Grief process more complex due to the absence of usual
support for grieving, healing
In the U.S. culture, kin-based relationships receive most
attention in cases of death
Experienced by nurses when need to grieve not
recognized
Can also be experienced by other “helping” professionals,
such as chaplains and clergy
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Complicated Grieving #1
Person void of emotion; grieving for prolonged periods;
expressions of grief seem disproportionate to event.
Previously existing psychiatric disorders may complicate
process.
Clients can experience grief when change encountered.
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Complicated Grieving #2
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
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Complicated Grieving #3
Risk factors leading to vulnerability
– Death of spouse or a 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)
– Maladaptive thoughts
– Dysfunctional behaviors
– Inadequate emotional regulation
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The Nursing Process: Assessment
All dimensions of human response (see Box 10.1)
Three critical components
– Adequate perception regarding the loss
– Adequate support while grieving for the loss
– Adequate coping behaviors during process
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The Nursing Process: Data Analysis and
Planning
Possible nursing diagnoses
– Grieving
– Complicated grieving
– Risk for complicated grieving
– Anticipatory grieving
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The Nursing Process: Outcomes
Examples: Client will:
o Identify effects of his or her loss
o Seek adequate support
o Develop plan for coping with the loss
o Recognize negative effects of the loss on his or her
life
o Seek or accept professional assistance if needed
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The Nursing Process: Interventions
Exploring perception of loss
– Cognitive responses
– Adaptive denial
Obtaining support
Promoting coping behaviors (see Nursing Interventions)
– Reviewing strengths of past coping
– Encouraging self-care
– Using communication, interpersonal skills
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3. Question #3
Is the following statement true or false?
Nurses commonly experience complicated grief.
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3. Answer to Question #3
False
Rationale: 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.
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The Nursing Process: Evaluation
Review of tasks and phases of grieving helpful in making
statements about client’s status.
Clients need support of trusted person.
Nurse must examine personal attitudes.
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Self-Awareness Issues
Examine one’s own experiences with grief and loss.
Take self-awareness inventory, reflecting on results.
Perform ongoing self-evaluation.
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