Learning Objectives
By the end of this section, you will be able to:
- Discuss social factors that influence grief and loss responses relating to the five stages of grief
- Discover the physical, social, and spiritual impacts of grief and loss
- Describe the impact of grief and loss on the nurse
Grief and loss are universal human experiences. As inevitable as they are challenging, these moments can shape individuals profoundly and permanently, influencing emotions, thoughts, behaviors, relationships, and even views of the world. The natural emotional response to loss, which is often most powerful when an individual loses someone or something deeply important to them, is called grief. This could include the death of a loved one, the ending of a significant relationship, or the loss of physical or mental health, among many other possibilities. Grief is complex, deeply personal, and can manifest differently for everyone, defying simple definitions or timelines. It can include a range of emotions, such as sadness, anger, confusion, guilt, and fear, and can also evoke a host of physical symptoms.
Related to grief, loss is not just to what has been taken away, but also to the secondary losses that might follow. These might include the loss of identity, routine, security, or future plans. Although intrinsically tied to grief, it has its unique complexities. A significant loss can change a person’s life trajectory and necessitate navigating a new, unfamiliar reality.
Understanding grief and loss involves many perspectives, from the psychological processes to the social and cultural contexts shaping how an individual mourns. It means acknowledging the less recognized or understood types of grief, such as anticipatory, complicated, and disenfranchised. The following section on grief and loss aims to provide a compassionate, comprehensive exploration of grief and loss for both clients and nurses.
Social Factors and Processes That Influence Grief and Loss
Social factors play a role in how individuals experience and navigate grief and loss. Cultural norms and traditions, societal expectations, and social support can significantly shape the grieving process. For instance, societies often have prescribed “grieving rules” that dictate who, how, and when people should grieve (Dayes et al., 2023). These norms can influence the legitimacy of one’s grief and can lead to disenfranchised grief, a type of grief that is not openly acknowledged or socially supported. For instance, consider the grief experienced by a person after the loss of a pet. While deeply impactful, this loss might not receive the same understanding or support as the loss of a human loved one. In nursing, disenfranchised grief can also manifest in situations like miscarriages, where the emotional impact on the mother and family might not be fully recognized by others, leading to feelings of isolation and prolonged grief (Thompson & Doka, 2017).
Social support is another critical factor. Social support systems, such as family, friends, and community groups, can provide emotional comfort, practical help, and a sense of belonging, all of which can facilitate the grieving process. Inadequate or unsupportive responses can compound feelings of loss, however, and make the bereaved feel more isolated (Peña-Vargas et al., 2020).
Societal expectations and stigma can also shape grief experiences. This can manifest as pressure to quickly return to normalcy and function effectively in society. Furthermore, societal stigma around death and grief can lead to silence and avoidance, exacerbating feelings of loneliness and distress (Cacciatore et al., 2021) and leading to complicated grief, characterized by prolonged and intense mourning (Shear et al., 2016). Complicated grief is a profound and prolonged response to loss that impacts a person’s ability to move forward. For example, consider a client who has lost a loved one and finds themselves unable to return to their daily activities or experiences severe emotional distress for an extended period, well beyond what might be considered a “normal” grieving process. They might struggle with intense feelings of disbelief, anger, or even guilt. In nursing, recognizing complicated grief is important because it can lead to significant mental health challenges (Mughal et al., 2019).
Withdrawal and Isolation
Withdrawal is a common, not necessarily unhealthy, side effect of grief, marked by a sense of pulling away from others and the world, a deep internalization of the grieving process. Withdrawing individuals may seem disengaged from their surroundings. This can be a crucial time for self-reflection and reevaluation, although others can misinterpret it as a lack of progress or healing (Vasquez, 2022).
Similarly, isolation is a common experience after losing a loved one, often occurring as part of the grieving process and frequently leading to withdrawal. The bereaved may experience isolation in various forms, including physical, emotional, and social isolation. Physical isolation may result from withdrawing from everyday activities and social interactions as part of the natural response to loss (Vasquez, 2022). The bereaved may spend time alone, reflecting on the loss and processing their grief.
Emotional isolation can lead to withdrawal. Even when surrounded by supportive friends and family, individuals who have experienced loss may feel misunderstood or disconnected due to their grief’s deeply personal and unique nature. They may feel that others cannot fully comprehend their pain, leading to feelings of loneliness.
Social isolation can also occur when social networks change after a loss. The bereaved may feel alienated or detached from their usual social groups due to the shared history and memories with the deceased. Furthermore, societal expectations and stigma around grief can exacerbate feelings of isolation (Pitman et al., 2018).
It is important to note that everyone’s grieving process is unique, and all may not experience withdrawal and isolation. While some may withdraw, others may seek social connection to cope with their loss. And while some degree of isolation may be a normal part of the grieving process, prolonged or extreme isolation can indicate a more serious issue, such as complicated grief or depression (Shear et al., 2016). Therefore, the individual may need professional help to assist in dealing with significant feelings of isolation after a loss. Thus, it is critical to provide individualized support during this time.
Kübler-Ross Model of Grief
The Kübler-Ross model, also known as the five stages of grief, is a psychological framework that describes the emotional process individuals go through when facing their mortality or experiencing significant loss. This model states that grief involves five stages: denial, anger, bargaining, depression, and acceptance (Kübler-Ross, 1969). These stages are not necessarily linear or experienced in a fixed order, and not everyone goes through all of them. They serve as a guide to understand the range of emotions people might encounter during a grieving process. Health-care professionals must remember that everyone’s grief is unique and may not neatly fit into these stages (Figure 9.2).
Denial
Denial is recognized as a significant stage in the grieving process, according to the Kübler-Ross model of grief (1969). The denial stage is often the initial response to a devastating loss, functioning as a defense mechanism that helps individuals cope with the initial shock (Stroebe et al., 2017). During this stage, individuals may refuse to acknowledge the reality of the loss or perceive it as a mistake or misunderstanding (Corr et al., 2018). For clients in this stage of grief, nurses can validate feelings without reinforcing denial. Gentle and compassionate communication can help the client gradually accept the reality of their situation (Tyrrell et al., 2023).
Anger
According to Kübler-Ross’s (1969) model of grief, anger is the second stage that individuals might experience after a profound loss. This stage is characterized by frustration, irritation, and even rage (Kübler-Ross, 1969). The grieving person might direct this anger toward themselves, others, or even inanimate objects, attributing blame for the loss that has occurred (Stroebe et al., 2017). Anger can also be a manifestation of deep pain, a reaction to feeling abandoned by the deceased, or a protest against the reality and finality of death (Corr et al., 2018). In this stage, nurses can create a safe environment for the client to express anger without judgment and use active listening and empathetic communication to facilitate expression of emotion. As with all stages of grief, the anger phase is not linear and may overlap with other stages or return later in the grieving process. Additionally, some people might not experience this stage, demonstrating grief’s individual and complex nature (Tyrrell et al., 2023).
Bargaining
According to Kübler-Ross’s (1969) model, bargaining is another potential stage in grieving. During this stage, individuals often make deals or promises to a higher power, the universe, or themselves, in an attempt to reverse or lessen the loss (Kübler-Ross, 1969). This stage typically involves “what if” and “if only” statements that reflect a desire to regain control over the situation (Stroebe et al., 2017). People may also fantasize about ways things could have been different, leading to a temporary escape from their pain (Corr et al., 2018). While this can provide temporary relief, extended time in this stage may prolong the grieving process if it prevents acceptance of the loss. In this stage, nurses may support clients in discussing their hopes, wishes, and concerns. They should also offer self and be open to conversations about spirituality or alternative treatments (Tyrrell et al., 2023).
Depression
Depression, as conceptualized in Kübler-Ross’s (1969) grief model, is typically the fourth stage in the grief process. Unlike clinical depression, this grief stage is characterized by profound sadness, despair, and loneliness that arise from the recognition and reality of the loss (Kübler-Ross, 1969). Individuals may exhibit symptoms, such as loss of appetite, lack of energy, sleep difficulties, and a general withdrawal from life and social activities (Stroebe et al., 2017). This stage of grief is not pathological but rather an expected response to a significant loss. It signifies an individual’s grappling with the loss’s impact and attempts to adjust to a new reality without the deceased (Corr et al., 2018). In this stage, nurses may offer empathetic support and validation of feelings of sadness and loss. They can also encourage expression of emotions and provide a supportive presence (Tyrrell et al., 2023). As with all stages of grief, the depression phase is not necessarily linear, and individuals might experience it in different ways and at different times during their grieving process.
Acceptance
According to Kübler-Ross’s (1969) model, the final stage of the grieving process is acceptance. Acceptance does not imply happiness or that the individual is “over” the loss. Rather, it signifies understanding and coming to terms with the reality of the loss (Kübler-Ross, 1969). During this stage, individuals often begin to look forward and engage more with life, albeit with the acknowledgment that it will be different than before (Stroebe et al., 2017). This stage is characterized by a sense of calm, a decreased anger or despair, and an increased ability to reflect on the loss without overwhelming pain (Corr et al., 2018). In this stage, nurses may celebrate small victories and support the client’s acceptance without minimizing their experiences and continuing to provide compassionate care and assistance (Tyrrell et al., 2023). For those who do experience this stage, it may not represent the end of grief but rather an integration of the loss into their life.
Unrealistic Expectations
The grieving process is highly personal and unique to each individual. As such, setting expectations, particularly unrealistic ones, can often hinder the process rather than facilitate it. One common unrealistic expectation is the belief that grief should follow a predictable, linear path, such as the five stages proposed by Kübler-Ross (1969). Grief is a complex process, often involving cycling between different emotions and stages (Stroebe et al., 2017).
Another common misconception is the expectation that grief has a distinct endpoint or a deadline when an individual will or should completely “get over” the loss. In many cases, individuals do not fully “move on” from their loss but rather learn to live with it and integrate it into their ongoing lives at their own pace (O’Connor, 2019).
The expectation that all individuals should display their grief openly or, conversely, should grieve in private is also unrealistic. Grief is experienced and expressed differently by different individuals, and all expressions of grief are valid (Stroebe et al., 2017). The key to healthy grieving is allowing individuals to experience and express grief in a way that feels right. Nurses facilitate an environment conducive to individualized grief expression through empathetic listening, personalized care, education, collaboration with interdisciplinary teams, and fostering a supportive community. This approach empowers individuals to navigate grief in a manner that feels right for them, fostering healing and resilience (Oates & Maani-Fogelman, 2022).
Impacts of Grief and Loss
Grief and loss can profoundly affect individuals, changing various aspects of their lives, including physical, mental, and overall well-being. Physically, grief can lead to symptoms, such as fatigue, changes in appetite, sleep disturbances, and even increased susceptibility to illness due to the stress and exhaustion it can cause (O’Connor, 2019). Mentally, individuals can experience sadness, anger, guilt, and anxiety and may even face an increased risk of conditions like depression and post-traumatic stress disorder (Stroebe et al., 2017).
Loss can also change an individual’s identity and understanding of the world. They may struggle with finding meaning in life after the loss, and their identity may change as they adjust to a new life and navigate the loss they have experienced (Bellet et al., 2020). Individuals endure various types of losses that can encompass physical, emotional, and spiritual realms, all of which can have an impact on their overall well-being. These losses can challenge a client’s sense of identity and self-worth, necessitating comprehensive support and care. Grief can also have social implications, as individuals may feel isolated or misunderstood by others, which can strain relationships (Mortazavi et al., 2020). The impact of grief and loss on an individual is multifaceted and extends far beyond emotional distress.
Physical
Grief and loss have significant physical impacts on individuals. The stress and emotional turmoil associated with grief can lead to a range of physiological symptoms. Fatigue, sleep disturbances, and changes in appetite are common among grieving individuals (Stroebe et al., 2017). In some cases, intense grief can lead to physical pain, such as chest pain or headaches (O’Connor, 2019).
Research also suggests that grieving individuals may experience weakened immune function, making them more susceptible to infections and illnesses (O’Connor, 2019). Furthermore, a prolonged period of intense grief, often called complicated or prolonged grief, can increase the risk of cardiovascular problems, high blood pressure, and even mortality (O’Connor, 2019). The physical impact of grief illustrates the intricate interplay between emotional distress and physical health, underscoring the need for comprehensive care for those dealing with loss.
Link to Learning
Visit Registered Nursing.org for more information on supporting clients and families with dying and grief.
Emotional
Grief and loss profoundly trigger various complex emotions. Feelings of sadness and despair are common, as is a sense of loneliness or isolation following a significant loss (Stroebe et al., 2017). The grieving individual may also experience guilt or regret, especially if there are unresolved issues or unexpressed feelings toward the deceased (Currier et al., 2015). Anger is another common emotional response; it may be directed at oneself, the deceased, other individuals, health-care providers, or even a higher power (Kübler-Ross, 1969). Additionally, anxiety can occur, including fears about mortality or the inability to cope with the loss alone (Mortazavi et al., 2020). In complicated grief, individuals may experience severe emotional distress, intrusive thoughts about the deceased, and difficulty accepting the death, which can significantly interfere with daily functioning (Duffy & Wild, 2017). Thus, the emotional effects of grief are multifaceted, illustrating the necessity of emotional support and care in times of loss.
Clinical Judgment Measurement Model
Applying the CJMM to the Stages of Grief
Walter has recently been diagnosed with dementia and is a new resident in the memory unit attached to the assisted living facility (ALF). Walter receives palliative care through the local hospice and already has legal documents in place to assist with his ongoing care.
Walter refuses to eat and tells staff to “get out” when they try to assist him with activities of daily living (ADLs), including bathing and hygiene. Walter says he just wants to be left alone to die. Walter refuses to leave his room and sits and stares at the floor. Nurses suspect that Walter is experiencing two stages of grief. Review this assessment of Walter’s grief using the steps of the Clinical Judgment Measurement Model (CJMM).
| CJMM Step | CJMM Data |
|---|---|
| Recognize Cues | History: Dementia and newly admitted to LTC; refuses to eat or leave room, tells staff to “get out,” stares at floor, refuses assistance with ADLs. States he wants to be left alone to die. |
| Analyze Cues | Dementia, depressed, angry, refusing care. |
| Prioritize Hypotheses | Grief Stages: (1) Anger, (2) Depression (The five stages are: denial, anger, bargaining, depression, acceptance.) |
| Generate Solutions | Establish trust and rapport, use therapeutic communication, involve Walter in decision-making, find out what he likes/enjoys and incorporate into care. |
| Take Action | Spend time with client, listen/offer self, offer choices, order his favorite meal, locate his favorite book, encourage family visits, use distraction techniques to get him to think of other things, ask him to tell you a story, ask his chaplain to visit. |
| Evaluate Outcome | If Walter is responsive, continue plan and continue to monitor. If not responsive, keep trying, make referrals as needed, ask the provider for antidepressant medication. |
Spiritual
The spiritual impacts of grief and loss are significant and can manifest in numerous ways. For some, a loss might prompt a deep questioning of their faith or belief systems, leading to a crisis of meaning. Individuals might grapple with questions about the nature of life and death, the existence of an afterlife, or the perceived fairness or justice of their loss. Sometimes, these questions can lead to spiritual distress or a loss of faith (Wong & Yu, 2021).
Link to Learning
Read this article for more information on spiritual well-being tools and how to support your own well-being.
Spirituality can also serve as a vital source of comfort and resilience in the face of loss. Many individuals find solace in their faith or spiritual beliefs, which can provide a sense of hope and meaning amidst their grief. Spiritual practices, such as prayer or meditation, can provide peace and connectedness (Biancalani et al., 2022). For some, the experience of loss can lead to spiritual growth or transformation. They may develop a deeper or more nuanced understanding of their beliefs or discover new spiritual perspectives that help them make sense of their loss (Eames & O’Connor, 2022).
Link to Learning
Access this site for more information on the spiritual assessment tool FICA and how to apply to nurse-client relationships.
Impact of Grief and Loss on the Nurse
The impact of grief and loss on nurses is significant, involving emotional, physical, and psychological components. Due to the nature of their work, nurses often develop close relationships with clients and their families, making them susceptible to feelings of loss when a client dies (Üstükuş & Eskimez, 2021). Emotionally, nurses may experience sadness, guilt, or helplessness, especially if they felt close to the client or if the death was unexpected (Kostka et al., 2021). They may also experience symptoms of grief similar to those held by the client’s family, such as disbelief, anger, and depression (McCallum et al., 2021).
Physically, the stress associated with grief and loss can lead to fatigue, sleep disturbances, and other health issues (Rahmani et al., 2023). Psychologically, the repeated experience of loss can contribute to burnout, a state of chronic physical and emotional exhaustion often associated with feelings of cynicism and detachment from work (Friganović & Selič, 2021). There is also an increased risk for compassion fatigue, characterized by a decreased capacity for empathy over time due to repeated exposure to traumatic events or losses (Gustafsson & Hemberg, 2022).
Cultural Context
Cultural Stigma: Potential for Nurses' Compassion Fatigue
Psychiatric and physical symptoms combine in culture-bound syndromes, which are mental health conditions specific to the client’s primary social group. Perceived experience with spiritual phenomena, or altered engagement in culture-based activities or rituals, may present during mental health care. Lack of understanding or acceptance, even lack of inquiry, on the part of the health-care providers may result in inadequate or delayed treatment, incorrect diagnosis, or stigma.
Nurses should seek culturally-informative education and evidence-based resources to help identify and address symptoms and cues that are difficult to interpret. Nurses can refer clients and families to community mental health and inquire as to peer services. Nurses are called to act as advocates to mitigate risks posed by stigma for conditions that may be poorly understood.
(Ahad et al., 2023)
In extreme cases, prolonged exposure to grief and loss without adequate coping mechanisms or support can result in traumatic stress responses similar to PTSD (Gabra et al., 2022). Dealing with grief can be emotionally challenging, especially for nurses who often witness and support clients and families through difficult situations. This is why it is important for nurses to employ self-care strategies in their daily lives. Some of these strategies include engaging in regular exercise, maintaining a balanced diet, and ensuring adequate rest. In addition, talking to colleagues, mentors, or support groups can provide an outlet to express emotions and share experiences, offering valuable emotional support. Nurses should also be mindful to recognize personal limits and establish clear boundaries between work and personal life to help prevent emotional exhaustion (Rabow et al., 2021). Health-care institutions need to recognize these impacts and support nurses, providing opportunities for debriefing, counseling services, and education about healthy coping strategies (Rahmani et al., 2023).
Life-Stage Context
Interventions for Assisting a Teenage Client with Grief After Loss
Psychoeducation
Understanding the stages and process of grief can be helpful for a teenager, particularly if this is their first significant loss. It can normalize their experience and reduce feelings of confusion or isolation. It can also prepare them for some of the different emotions they may experience, helping them understand that grief is not a linear process.
Individual Therapy (CBT, EMDR)
Cognitive behavioral therapy can help teenagers manage and understand their emotions and develop coping strategies. Eye Movement Desensitization and Reprocessing (EMDR) could be considered if the teenager is experiencing traumatic grief, helping to process the traumatic elements of the loss.
Group Therapy
Participating in group therapy with other teenagers experiencing grief can foster a sense of community and reduce feelings of isolation. They can share experiences and coping strategies and support each other in a safe and controlled environment.
Art Therapy or Expressive Arts Therapy
Teenagers may struggle to articulate their emotions verbally, especially if they are intense or confusing. Art therapy provides an alternative medium through which they can express their feelings. Creating art can also be a therapeutic process, serving as a distraction and providing a sense of accomplishment.
Physical Activity
Regular physical activity can improve mental health by reducing anxiety, depression, and negative mood and improving self-esteem and cognitive function. Exercise is a powerful tool to help teenagers manage grief-related stress and insomnia.
Mindfulness and Relaxation Techniques
Techniques, such as yoga, meditation, and deep breathing, can help teenagers manage the physical symptoms of grief, such as tension and difficulty sleeping. They can also promote a sense of calm and control, which can be particularly helpful in times of intense emotion or stress.
Family Therapy
The death of a close friend or relative affects the whole family. Family therapy can help each member understand the others’ grief process and coping mechanisms. It can improve communication and help the family support each other effectively.
School-Based Support
Schools can provide resources and create an environment conducive to healing. This may involve coordinating with teachers and administrators to ensure the teenager can access grief counseling, time off as needed, and academic support.
All these interventions should be tailored to the teenager’s unique needs, cultural background, and personal preferences. These strategies aim to support them during this difficult time and equip them with coping mechanisms to manage their grief.