Learning Objectives
By the end of this section, you will be able to:
- Identify concepts of grief
- Recognize concepts of loss
- Describe reactions to grief and loss
We often think of loss and grief in the context of the end of life. However, loss can be associated with many other life experiences, including divorce, estrangement, financial loss, job loss, medical diagnoses, and traumatic events. While the grief process is highly variable, individuals can experience grief in response to any of these life experiences, events, and losses.
Expressions of grief may present as physical symptoms, emotional responses, or changes in social interactions. While researchers have developed a comprehensive knowledge of grief patterns, everyone is unique and moves through grief stages at different rates and with various challenges. Nurses need to understand these differences to provide individualized care for patients who have experienced loss.
Concepts of Grief
The emotional response to a loss, known as grief, is defined as the individualized and personalized feelings and responses that an individual makes to real, perceived, or anticipated loss. These feelings may include anger, frustration, loneliness, sadness, guilt, regret, and peace. Major concepts associated with grieving are loss, mourning, and bereavement. The actual or perceived absence of a possession, circumstance, or individual is called loss. The response to loss is grief, and the outward, personal expression of grief is mourning. After a patient dies, the family members and other survivors experience loss. However, the experience of grief may also be associated with the loss of health or with changes in relationships or roles.
Mourning
The outward, social expression of loss is called mourning. Individuals outwardly express loss based on cultural norms, customs, and practices, including rituals and traditions. Some cultures may encourage the verbal expression of emotions: for example, by wailing or crying loudly. Other cultures are more stoic and promote a minimal reaction to loss. Culture also dictates how long one mourns a death and sometimes how a person in mourning is expected to behave. The outward expression of loss is also affected by an individual’s personality, previous life experiences, and social support system.
After a death, mourning practices include funerals, wakes, and other rituals, often connected to spiritual beliefs. These practices are highly variable among cultures. Because nurses will encounter patients from a wide range of cultures, accepting individual mourning practices is essential. Mourning rituals may include the following:
- prayer
- meditation
- chanting (rhythmic and repetitive vocalization of words or sounds)
- singing
- wailing (prolonged, high-pitched, mournful cries)
- gathering of family
- presence of spiritual leaders
- fasting
- reading from a spiritual book
- applying herbs or oils
- covering or dressing the deceased’s body
Link to Learning
Learn more about unique burial rituals worldwide, from sky burials to parades.
Bereavement
Both the feelings of grief and the outward expression of mourning after a loved one has died are known as bereavement. A bereavement period is the time it takes for the mourner to process the loss, grieve, and mourn. There is no set bereavement period; everyone will adjust differently to the world without the presence of the deceased. Bereavement can take a physical and emotional toll on a person who has experienced loss.
Nurses can encourage a person who is bereaving to talk about the death and understand their feelings are normal. Individuals experiencing the bereavement process should allow for sufficient time for the expression of grief and, if possible, postpone significant decisions such as changing jobs or moving. If individuals connect with a specific religion or spiritual practice, leaning into these beliefs enhances coping during this difficult time. Individuals without a religious connection may still experience grief on a spiritual level; they can be encouraged to incorporate their individual beliefs on death and dying into healthy coping strategies. In all these instances, nurses offer individuals a sense of acceptance by encouraging them to express grief in their own way.
Expression of Grief
Grief affects survivors physically, psychologically, socially, and spiritually. The grief process is not orderly and predictable. Emotional fluctuation is normal. There are times when the person experiencing the loss may feel in control and accepting, and there may be other times when the loss feels uncontrolled and unbearable. Normal grief reactions to a loss can consist of physical symptoms, intense emotions, cognitive changes, and outward behavioral changes. These reactions affect social interactions in a variety of ways.
Physical
Individuals experience a range of physical symptoms during acute and long-term grief. Common physical symptoms associated with grief include the following:
- hollowness in the stomach
- tightness in the chest
- weakness
- heart palpitations
- dizziness
- sensitivity to noise
- shortness of breath
- muscle tension
- fatigue
- dry mouth
- eye irritation
These physical changes result from physiologic changes that occur within the body in response to stress hormones triggered by the grief response. Some of these physiological responses include the following:
- blood vessel constriction
- elevated blood pressure
- increased heart rate
- release of inflammatory chemicals
- increased platelet and fibrinogen activity
In addition to bodily sensations, individuals experiencing grief also report intermittent and sometimes chronic changes in their cognitive state. Some examples of cognitive symptoms include the following:
- depersonalization (feeling disconnected from one’s own feelings and experiences)
- confusion
- forgetfulness
- trouble concentrating
- dreams of the deceased
- idealization of the deceased
- a sense of the presence of the deceased
By simply naming these common symptoms as part of the natural grieving process, nurses can help normalize the symptoms, thereby reducing an individual's sense of aloneness. Nurses caring for grieving individuals can help distinguish between expected symptoms of grieving and more serious underlying health issues. These symptoms may present as acute physical changes or emotional dysregulation, as previously noted. Much is known about managing physical symptoms associated with emotional dysregulation, and it can be applied to individuals experiencing grief. Nurses can encourage such activities as:
- healthy eating
- staying hydrated
- body movement
- massage
- deep breathing exercises
- maintaining healthy sleep patterns
Life-Stage Context
Broken Heart Syndrome
Stress-induced cardiomyopathy, also known as Takotsubo cardiomyopathy (TC), is a heart condition often associated with increased stress (Ahmad et al., 2023). It is also recognized as “broken-heart syndrome” within the healthcare community. While this disorder is uncommon, it presents most often in older women after an acute stress event such as:
- death of a spouse
- death of a relative
- traumatic accident
- diagnosis of medical illness
- extreme financial loss
The pathophysiology of TC is not fully understood, but it is thought to be associated with inflammatory chemicals, microvascular dysfunction, decreased estrogen levels, and coronary spasms, among others (Ahmad et al., 2023). Highly stressful events trigger reduced mobility in the left ventricle muscle fibers. This results in decreased ventricular systolic function, decreased overall cardiac output, and auscultatory systolic murmur. Symptoms are similar to acute coronary syndrome (ACS) or myocardial infarction (MI), including the following:
- chest pain
- shortness of breath
- tachycardia
- bradycardia
- arrhythmias
- systolic murmur
However, lab values suggesting cardiac damage may not show elevation consistent with the symptoms experienced. Because TC mimics other acute heart conditions, nurses should care for patients with TC in the same way as patients experiencing an MI (Ahmad et al., 2023). Patients are stabilized in a hospital setting; however, recovery as an outpatient is expected, with chest pain symptoms typically resolving after several weeks.
Emotional
Physical and emotional symptoms associated with the grief response are closely linked. The physical symptoms of fatigue, chest tightness, breathlessness, or heart palpitations are related to common emotional symptoms such as anxiety, anger, and fear. Conversely, a person may develop anxiety related to physical symptoms associated with grief. Other emotional sensations commonly reported during the grief response include the following:
- numbness
- sadness
- shame
- loneliness
- relief
- yearning (a feeling of intense longing)
- guilt
- self-reproach (harsh self-criticism or disapproval)
- helplessness
- abandonment
Many strategies that are effective at reducing physical symptoms of grieving can also help alleviate emotional distress. In addition, speaking with a specially trained grief counselor can positively impact emotional dysregulation. As individuals progress through the grieving process, nurses can encourage them to do the following:
- Express creativity.
- Accept rapidly changing emotions.
- Practice patience with self and others.
- Incorporate frequent self-care activities.
- Express feelings in an emotionally safe environment.
- Maintain a consistent routine.
- Maintain connection with the deceased.
- Maintain connection with family and friends.
- Reach out to community through support groups.
Link to Learning
Coping with grief is difficult, but nurses can promote simple tasks to help patients maximize their support during the different stages of grief. While formal counseling may benefit some, focusing on simple, day-to-day tasks such as getting proper sleep, hydration, and nutrition can also be highly effective. Check out this article on ways to encourage and support patients through the grief process to learn more.
Social
Individuals may have difficulty interacting with others during the initial stages of grief. People report having trouble maintaining conversation, making plans, and attending social gatherings, even with close family and friends. This social disruption can last indefinitely and is also associated with increased stress levels and many of the physical and emotional symptoms previously discussed. Individuals may struggle with tasks and interactions such as the following:
- work performance
- uncontrollable crying
- social withdrawal
- over-reactivity
- changed relationships
- avoidance of reminders of the deceased
- rage or anger
Anger is a volatile emotion common for those experiencing a loss, particularly an unexpected one. Anger may be held inward or directed outward toward others. Nurses should encourage individuals to verbalize their anger and offer compassionate listening without judgment as a way for people to work through their feelings of anger.
Concepts of Loss
While loss is often thought of in the context of death and dying, many examples of loss are not associated with death. Some loss is perceived only by the individual experiencing it; other types of loss are readily visible to other individuals. This variation in types of loss may affect the grieving process. Table 36.1 explains the various concepts of loss.
| Concept | Explanation | Examples |
|---|---|---|
| Actual loss | Actual loss refers to the tangible, measurable loss of something that was once possessed or experienced. | The death of a loved one, loss of a job, loss of a limb in an accident |
| Perceived loss | Perceived loss is the subjective experience of loss, even if no tangible loss has occurred. | Feeling a sense of loss after a breakup or divorce, loss of a cherished dream or goal |
| Anticipatory loss | Anticipatory loss involves experiencing grief and mourning in anticipation of an impending loss. | Grieving the impending death of a terminally ill family member or pet |
| Maturational loss | Maturational loss refers to the loss experienced as a result of developmental milestones and life transitions. | Leaving home for college, retirement, becoming an empty-nester |
| Situational loss | Situational loss is the loss experienced due to specific circumstances or events. | Loss of a home due to a natural disaster, loss of financial stability after bankruptcy |
Actual Loss
In addition to death, individuals may experience loss as the absence of an individual, a pet, a possession, a relationship, a job, a body part, or overall health. In actual loss, the absence is clearly noticed by others. This support reinforces the validity of the grief process and allows individuals the social and cultural space for grieving.
Perceived Loss
A perceived loss is more complex in that the loss may not be evident to others. There is no observable loss, but the individual distinctly feels an absence. This may occur in a variety of situations, such as the following:
- disruption in identity
- changes in mental acuity
- change in housing stability
- loss of independence
- decreased mobility
- change in friendship dynamics
- disruption in spiritual beliefs
- loss of trust
Patient Conversations
Perceived Loss
Scenario: Carlyn is a retired 75 year old who enjoys taking walking tours around the world and hiking with her children and grandchildren in national parks around the country. She also enjoys reading, trying new restaurants, and drawing. Over the last year, she has been struggling with pain in her right knee after a fall during a hike. Carlyn has been unable to complete any hikes over one mile long during the past year. Her daughter is concerned that Carlyn is depressed and convinces Carolyn to make an appointment with her primary care provider today. Jace, an RN, is taking Carlyn’s history.
Nurse: What brings you in today, Carlyn?
Patient: My daughter thinks I am depressed. She is concerned because I haven’t planned any trips and am just not interested in eating out anymore. She says I stay inside all the time, which is unlike me.
Nurse: Your daughter must be really worried about you. It sounds like you are feeling a lack of interest in your usual activities. Are you feeling down or depressed or having trouble sleeping?
Patient: I’m sleeping fine, but I am feeling down because of my knee.
Nurse: I know your knee has been painful over the last year. Do you think this pain is contributing to your decreased activity level?
Patient: Well, my pain has been better in the last few months, but that’s because I have been taking it easy. I can’t hike anymore, and all my travels in the past have been walking tours. I really miss that. I know it seems silly, but I really feel like I lost part of myself when I stopped being able to hike.
Nurse: Have you expressed these feelings before or talked about them with your family?
Patient: Not really; I don’t think anyone can understand that being unable to walk and hike changes how I see the world. Sometimes, I feel overwhelmingly sad about this.
Nurse: Carlyn, I think you may be dealing with grief related to the loss of hiking. This type of loss is referred to as a perceived loss. It is sometimes complicated for others to understand perceived losses because they can’t see or feel the loss themselves; however, grieving the loss of a vital part of your identity, such as hiking, is essential. I encourage you to let yourself feel the sadness as grief and seek a counselor or support group to help you with coping skills.
Patient: Thank you, Jace, for listening. And for helping me understand this is a normal feeling that others might not understand. I will talk with my family so we can come up with ways for me to cope with this grief.
Anticipatory Loss
When an individual expects or foresees a loss or change it is known as anticipatory loss. This type of loss creates anxiety about a loss before it happens. Anticipatory loss is common and occurs in situations such as the following:
- chronic illness
- terminal illness
- cognitive changes such as dementia
- divorce
- expected changes in life stage
Anticipatory loss can cause a prolonged grieving process as well as create relationship tension if a person begins to withdraw prematurely from social connections. For example, a grandmother may feel anger, guilt, and sadness, anticipating the loss of being present as her grandchildren grow up. She may feel compelled to overextend herself physically and emotionally to spend time with them. A father may feel anxiety and anger associated with the anticipated loss of time with his children after a divorce. This may lead to conflict in creating a parenting plan with his ex-spouse. Nurses can engage with patients about anticipatory loss similarly to actual loss. Bringing in coping mechanisms will help in the present moment and also help prepare the individual for when the actual loss occurs.
Maturational Loss
A maturational loss occurs at predictable intervals during an individual’s life span. They are often tied to life stages (Table 36.2) (Child Care Resource Center, n.d.). Every individual will experience them differently. Maturational losses may lead to grief responses for some people; other people may simply experience them as a process of moving forward to a new stage of life.
| Life Stage | Triggers for Maturational Loss |
|---|---|
| Early childhood |
|
| Middle childhood |
|
| Adolescence |
|
| Early adulthood |
|
| Childbearing |
|
| Middle adulthood |
|
| Older adulthood |
|
Life-Stage Context
Grief in Children
Children understand and process death differently than adults. The grief process and symptoms in children vary based on the age of the child. Young children may be unable to verbalize their emotions and feelings, but support is crucial at any age.
Symptoms of grief in younger children include nervousness, uncontrollable rages, frequent sickness or accidents, rebellious behavior, hyperactivity, nightmares, depression, compulsive behavior, memories fading in and out, excessive anger, overdependence on the remaining parent, denial, and disguised anger. Children may not understand that death is permanent until they are in preschool or older. To help facilitate this understanding, it is important to use the word “death” and not euphemisms like “gone to sleep” or “gone away.”
Symptoms of grief in older children include difficulty concentrating, forgetfulness, decreased academic performance, insomnia or sleeping too much, compulsiveness, social withdrawal, antisocial behavior, resentment of authority, over-dependence, regression, resistance to discipline, suicidal thoughts or actions, nightmares, symbolic dreams, frequent sickness, accident proneness, overeating or undereating, truancy, experimentation with alcohol or drugs, depression, secretiveness, sexual promiscuity, and running away from home.
Play is the universal language of children, so nurses should use it therapeutically when possible. Reassuring children that their grief is “normal” can give them comfort. If necessary, refer children, parents, and families to grief specialists.
Situational Loss
A situational loss can encompass other types of loss but primarily describes losses associated with expected or unexpected life changes for an individual. These can include the following:
- loss of potential to have children
- loss of hope for achieving a dream
- loss of friends due to moving
- loss of body image
- loss of control
- loss of freedom
- loss of physical or emotional safety
- leaving childhood home
- going away to college
- moving to a new home
- graduating from school
- starting a new school
Situational losses may be sudden or anticipated. Situational grief is highly variable, with some individuals reacting with prolonged symptoms and others not having a grief response at all.
Reactions to Grief and Loss
Reactions to loss and grief are often profoundly personal, but they are also affected by cultural and social expectations. Sometimes the reactions of others, including family, friends, and the wider community, can affect the grief process. Furthermore, a variety of cultural differences are associated with grieving.
Researchers have developed frameworks (e.g., Engel’s Six Stages, Kübler-Ross’s Five Stages) that are helpful for nurses in visualizing the stages of grief. Having a clear understanding of these stages allows nurses to support patients and families during the grief process. Based on these concepts, nurses will recognize specific emotional reactions as symptoms of grief and can help equip patients with appropriate coping strategies. Though the stages of grief provide a helpful framework, nurses must remember that each individual progresses through the experience of loss at their own pace. Setbacks and fluctuations through the stages are typical and even expected.
Engel’s Six Stages
American psychiatrist George Engel proposed his theory of grief in 1961. He wanted to answer the question, “Is grief a disease?” His answer compares the death of a loved one to a physical injury. The loss creates similar responses in the body as a physical wound, and the grief response is essentially a deviation from a normal state of health. The body requires a certain process to return to a state of normalcy or health. According to Engel, this process of grief consists of six stages (Registered Nursing, 2023):
- shock and disbelief
- developing awareness
- restitution
- resolving the loss
- idealization
- outcome
While the timeframe to proceed through these stages is not universal, Engel believed these stages occur sequentially. Initially, the person experiencing loss through death is in a state of disbelief, or shock, and refuses to accept the loss; some individuals report not feeling their loss as real. This is followed by an awareness of the finality of the death, after which they work through their own personal and cultural rituals in response to grief. As a sensation of resolution begins to occur, the individual may attend support meetings and open up with friends and family about the loss. Exhibiting a sense of idealizing the deceased person is also common. During the final stage, or outcome, Engel proposed that healing and maximum coping occurs, allowing the bereaved to adjust to life without the deceased.
Kübler-Ross’s Five Stages
A few years after Engel proposed his stages of grief, Swiss psychiatrist Elisabeth Kübler-Ross identified five main stages of grief: denial, anger, depression, bargaining, acceptance (Tyrell et al., 2023). Patients and families may experience these stages along a continuum, move randomly and repeatedly from stage to stage, or skip stages altogether. As Figure 36.2 illustrates, there is no correct way to grieve, and an individual’s needs and feelings must remain central to care planning.
Denial
When the grieving individual refuses to acknowledge the loss or pretends it isn’t happening, denial occurs. The feeling of denial is self-protective, as the individual attempts to numb overwhelming emotions as they process the information. The denial process can help to offset the immediate shock of a loss. Denial is commonly experienced during traumatic or sudden loss or if other unexpected, life-changing events occur. For example, a patient who presents to the provider with a severe headache and receives a diagnosis of terminal brain cancer may experience feelings of denial.
Anger
In the grief process, anger often masks pain and sadness. The subject of anger can be quite variable: displeasure or hostility may be directed at the individual who was lost, internalized against the self, or projected toward others. Additionally, an individual may lash out at those uninvolved with the situation or have bursts of anger that seemingly have no apparent cause. Healthcare professionals should know that anger may often be directed at them as they provide information or care. Healthcare team members, family members, and others who become the target of anger must seek to recognize that it is not a personal attack but rather a manifestation of the challenging emotions that are a part of the grief process. The nurse can provide a supportive presence and allow the patient or family member time to vent their anger and frustration while maintaining boundaries. Rather than focusing on what to say or not to say, allowing a safe place for a patient or family member to verbalize their frustration, sorrow, and anger can offer great support.
Bargaining
During the grief process bargaining can occur as the bereaved attempts to regain control over the loss. When individuals enter the bargaining phase, they seek ways to change or negotiate the outcome, regardless of whether this is realistic or even possible. Some may try to “make a deal” with God or their higher power to take away their pain or change their reality; they may promise to live a better life or give more of themselves to religious practices if only the circumstances were different. For example, a patient might say, “I promised God I would stop smoking if He would heal my wife’s lung cancer.”
Depression
Prolonged sadness that affects an individual’s ability to perform everyday tasks is called depression. As part of the grief process, depression can manifest as intense sadness over the loss of a loved one or a similarly life-changing situation. It can cause a loss of interest in activities, people, or relationships that previously brought one satisfaction. It is not uncommon for individuals in the depression stage of grief to experience irritability, sleeplessness, significant fatigue, and loss of focus or energy. Simple tasks such as getting out of bed, showering, or preparing a meal can feel so overwhelming that individuals withdraw from activity. They may struggle to find meaning in their life or to identify their sense of personal worth or the value of their contributions. Depression can be associated with ineffective coping behaviors, and nurses should watch for signs of self-medicating with alcohol or drugs to mask or numb depressive feelings.
Acceptance
The final stage of grief, acceptance, happens when the individual understands their loss and acknowledges their new reality. They begin to re-engage with others, find comfort in new routines, and even experience happiness with life activities again. The acceptance phase does not mean the absence of sadness or struggle; rather, it signifies the individual’s ability to cope with the grief experience.
Unfolding Case Study
Unfolding Case Study #5: Part 6
Mr. Morales is at the oncology clinic, accompanying his wife who is undergoing treatment for aggressive breast cancer. The oncologist has just explained that Mrs. Morales has a type of cancer that is not responding effectively to treatment and hospice care is recommended at this time. Mr. Morales is visibly upset and states, “No. No. This can’t be happening. She’s young and healthy! This isn’t fair! You’re wrong! I want a second opinion right now. Get out and get someone in here that can give us a better answer!” Mrs. Morales begins to cry and says, “No. I refuse to believe it. I’ve been doing my treatments every day like I should. There’s no way this is true.”
Tasks of Grieving
Other experts also describe the normal grieving process in terms of tasks that one must accomplish. These tasks include notification and shock, experiencing the loss, and reintegration.
- Notification and shock: This phase occurs when a person first learns of the loss and experiences feelings of numbness or shock. The person may isolate themselves from others while processing this information. The initial step for the individual is to accept the reality of the loss by evaluating and acknowledging it.
- Experiencing the loss: The second task involves experiencing the loss emotionally and cognitively. The person must work through the pain of separation and grief by reacting to and expressing it.
- Reintegration: The third task involves reorganizing and restructuring family systems and relationships by adjusting to the environment without the deceased. The person must form a new reality without the deceased and adapt to a new role, while also retaining memories of the deceased.
As a nurse, you can greatly assist patients and family members as they move through the grieving process by being willing and committed to spending time with them. Listen to their stories, be present, and witness their pain. Remember that you cannot fix everything, but taking time to assess their symptoms of grief helps you identify other resources for support.
Complicated and Dysfunctional Grief
A disorder called complicated grief can occur after the death of a significant other. With this, the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment. A specialized grief therapist may be necessary to address complicated grief.
Clinical Judgment Measurement Model
Generate Solutions: Grief After Suicide
Nurses generate solutions by identifying actions or interventions to best address patient issues. Recognizing solutions to help patients cope with grief after the suicide (death caused by intentional harm to oneself) of a loved one is crucial. Suicide is often associated with complicated grief patterns that nurses must recognize to provide essential care. Nurses can watch for factors that can signal complicated grief that fails to follow normal expectations and leads to functional impairments. Complicated grief can present with the following:
- prolonged anxiety
- symptoms of post-traumatic stress disorder
- survivor guilt
- substance misuse
- prolonged sleep disorders
- nightmares
- lack of concentration
- inability to pursue everyday tasks
By identifying specific risk factors and common patterns of complicated grief, the nurse can create a safe environment for the patient to express themselves. With a nonjudgmental attitude, the nurse can help the patient seek support services, grief counseling, and mental health services as appropriate.
Complicated grief may become dysfunctional grief in which grief does not resolve as expected or an individual resorts to unhealthy coping strategies. This type of complicated grief is more common in response to traumatic deaths, violent deaths, unexpected deaths, death of romantic partners, and in parents experiencing the loss of a child. Dysfunctional grief may or may not follow the typical pattern of processing through the grief stages, but it frequently leads to secondary physical and emotional problems. Table 36.3 displays types of dysfunctional grief, including chronic grief, delayed grief, exaggerated grief, and masked grief.
| Type of Dysfunctional Grief | Clinical Example |
|---|---|
| Chronic grief | A 70-year-old man continues to sob on a regular basis and has difficulty taking care of himself three years after the death of his wife in a car accident. |
| Delayed grief | A 16-year-old girl insists on continuing all her activities, social engagements, and school projects after the death of her mother. For many months, she tells her friends and family that she is “fine.” During her birthday celebration, she is overwhelmed with sadness and begins to exhibit normal grief reactions. |
| Exaggerated grief | An 8-year-old boy expresses grief in response to the death of his older brother by experiencing nightmares, extreme fear of illness, and misbehaving at school. |
| Masked grief | The son of a 70-year-old woman is concerned when his mother begins to experience new symptoms, such as heartburn and headaches, after the death of her husband. |
To assist in treating complicated and dysfunctional grief, providers typically obtain a comprehensive grief assessment of the bereaved. A variety of standardized clinical tests can be used for this purpose, including the following:
- Pathological Grief Items Checklist
- Hamilton Rating Scale for Depression
- Inventory of Complicated Grief
- Hogan Grief Reaction Checklist
- Beck Depression Inventory
- Texas Inventory of Grief
- Social Adjustment Scale
Link to Learning
Standardized and validated questionnaires such as the Inventory of Complicated Grief can help nurses accurately evaluate grief and provide appropriate interventions based on the results.